11 Biggest Sports Medicine Trends for 2011

Laura Dyrda -   Print  |
An increasing number of new orthopedic physicians are training in the sports medicine specialty and turning their practices into true sports medicine facilities. Hospitals across the country are following this trend as well, creating sports medicine centers that offer services and programs for active patients. The influx in numbers of patients seeking sports medicine physicians could be attributed to several factors, including the increasing population of older adults who want to remain active and a greater emphasis on competitive youth sports. Sports medicine physicians and athletic training professionals discuss the biggest trends in sports medicine that will spark debate in 2011.

1. Multidisciplinary sport medicine practices.
Sports medicine goes far beyond the surgical treatment for injured athletes to incorporate athletic trainers, physical therapists, nutritionalists and sports psychologists. The most successful sports medicine practices understand each aspect of an athlete's care and incorporating those services into the practice. Robert J. Nicoletta, MD, director of the division of sports medicine at Cambridge Health Alliance, a Harvard-affiliated health system around the Boston area, says the sports medicine practices of the future will routinely bring all those services under one roof for their patients as well as create room in the facility for primary care sports medicine physicians.

As a first step toward making a sports medicine practice more multidisciplinary, many practices are now hiring athletic trainers to serve as physician extenders. "Traditionally, athletic trainers worked in high schools, colleges and professional settings," says Robb S. Rehberg, PhD, ATC, CSCS, NREMT, a partner with The Rehberg Konin Group in Wayne, N.J.

More athletic trainers are working exclusively in the practices, taking on responsibilities such as seeing patients for physical exams and follow-up appointments, devising rehabilitation plans, assisting with billing and administrative responsibilities and assisting in the operating room. "There are so many different areas where an athletic trainer can help because of their versatility and musculoskeletal background training," says Dr. Rehberg.

2. Sports injury prevention programs. A large portion of many sports medicine practices focuses on treatment for athletes, especially for young athletes. Some of the most successful sports medicine physicians partner with area schools and stand on the sidelines during practices and games to help if an athletes is injured. Other physicians open "sports injury clinics" on Saturday mornings to treat injuries from the previous night's games. The American College of Sports Medicine and the American Orthopaedic Society for Sports Medicine are hoping to reduce the needs for these services by recently embarking on campaigns to promote sports injury prevention, says Jonathan Chang, MD, a physician with Pacific Orthopaedic Medical Group in Alhambra, Calif., clinical assistant professor at the University of Southern Califonia and a spokesperson for AOSSM and ACSM. Both organizations are putting time, effort and capital into creating resources for sports medicine practices and physicians to launch educational prevention programs for athletes.

One of the biggest challenges in prevention will be implementing programs for ACL injury prevention in women. "Women have four times greater chance of having ACL injury as men in the same sport," says Dr. Chang. "We think we have identified the reasons why and we also seem to know that many of those injuries are preventable. The challenge comes in implementing a program that is cost-effective and interesting for girls." In the future, Dr. Chang says sports medicine practices will focus programs on female athletes, especially young athletes, on the best ways to prevent ACL injury.

3. Knee surgery. Advances in ligament reconstruction and biomechanics are providing the technology and equipment necessary for procedures that will reproduce the patient's ligament as closely as possible. Double bundle knee replacements have begun to address the reproduction of the natural motion of the knee and anatomically shaped knee implants allow for an increased range of motion. "We've learned that the normal ACL is made up of two bundles and they both provide stability to the knee at different ranges of motion," says Dr. Nicoletta. "We're trying to reproduce the exact attachment site, reconstructing it like it was before the patient was injured. In the long run, the idea is that patients will have more stability and less arthritic changes as a result of anatomic reconstruction." Over the next few years, research into biomechanics and developing scaffold for a better healing environment will provide better outcomes for ligament reconstruction surgery.

4. Technologies for knee reconstruction and repair.
Technology for knee surgery has made great advances over the past few years and will continue to grow into the future. "One of the big challenges in knee treatments remains articular cartialge damage," says Jack Farr, MD, a physician with OrthoIndy in Indianapolis. "As the damage progresses, it evolves to frank degenerative joint disease--often requiring joint replacement. The accepted projection is that total knee replacement volume will rapidly expand over the next 10 years. While these patients may be too far advanced for cartilage restoration, in the big picture, the goal is to restore these articular cartilage lesions in their early phase in an attempt to potentially avert this progression to knee replacement. There are currently several treatment options for articular cartilage lesions, but the options in the United States haven't changed greatly over the past 10 years with the exception of particulate juvenile allograft cartilage (DeNovo NT, ISTO/Zimmer) introduced in 2007. On the other hand, the cartilage restoration options have been rapidly expanding in Europe."

There are now three new US based cartilage technologies that are in Phase III trials now or are projected to begin Phase III trials in early 2011. These have the potential to impact the cartilage restoration landscape and include: Histogenics' NeoCart, CAIS from DePuy/Mitek and the Zimmer DeNovo ET. Even with successful trials, these products won't be on the market for several years, but if approved they will join Carticel (Genzyme) and DeNovo NT (ISTO/Zimmer) in the cell therapy market.

In the meniscal arena, the only approved scaffold (Menaflex, Regen) lost FDA approval. While there are a variety of third generation meniscal repair systems, the only new augmentation for meniscal repair healing are small bioabsorbable tubes (BioDuct, Stryker) that appears to allow cells to migrate from the periphery of the meniscus to the tear site. A post market release study of the BioDuct is projected to start Q4 2010. While this trend is advantageous for the patients, it presents challenges for the physicians when deciding which treatment method will work best for their patients. "As cartilage restoration matures, finding the right treatment for the right lesion for the right patient will be an ongoing evolutionary process, especially when socioeconomics are added into the equation," says Dr. Farr.

5. Stem cell treatment for cartilage injuries.
Continued developments in stem cell research will develop the best methods for biologic cartilage repair, says Dr. Nicoletta. Biologics will be important to sports medicine because physicians are able to use material from the patient's body to generate healing instead of purchasing synthetic products. Current research shows stem cells may encourage better outcomes for patients, though the long-term effects of stem cell use is still unknown.

In the future, researchers and physicians will focus on regenerating cartilage, says Dr. Nicoletta, which will provide better outcomes for repairing cartilage damage. Gene therapy and tissue engineering will also be important aspects of biologic treatment in the future. "There has been a lot of interest in rotator cuff injuries and the biology of trying to get that healed with minimally invasive surgical techniques and biologic implants," says Dr. Nicoletta.

6. Platelet rich plasma. While some surgeons report positive outcomes from platelet rich plasma injections, others feel the injections are no better than a placebo. PRP is currently used to treat tendon and ligament injuries. Team physicians for professional athletes have been using PRP injections for the past few years with the objective of promoting a quicker return-to-play. At the moment, there are no significant clinical studies on the effectiveness of PRP injections, says Gary Misamore, MD, a physician with Methodist Sports Medicine/The Orthopedic Specialists in Indianapolis.

The first studies on PRP were presented at the AOSSM annual conference this past summer found that patients did not experience substantial improvement after PRP injections, says Dr. Chang. "It's not that we think it doesn't work like it's supposed to," he says. "We haven't been able to standardize a process for how to prepare and use it."

Practices cannot use CPT codes for PRP injections in conjunction with surgical procedures, which means many patients pay out-of-pocket for the injection. David Geier, MD, a physician with MUSC Sports Medicine in Charleston, S.C., predicts that if future studies show PRP injections are effective, insurance companies will begin covering the expenses.

While the injection may not help the patient, it won't damage the patient either, says Dr. Misamore. In practices where physicians are choosing to perform PRP injections, Dr. Geier says nurses will be trained to draw the blood and spin it in the centrifuge, saving time for physicians. This type of delegation is already happening in some practices. "If you can make patients better without surgery, that's a good thing to do," says Dr. Geier.

7. Shockwave therapy. In the United States, using shockwave therapy to treat chronic injuries, such as plantar fasciitis, is well known but still relatively new when employed to treat acute injuries such as sprains, muscle pulls and over extensions. In the past, many professional athletes have sought out shockwave therapy to recover from injuries as opposed to using cortisone shots or more traditional treatments.

"Shockwave treatment is a way to quickly produce the results of a very good deep tissue massage with less effort from the therapist or trainer who performs the treatment," says Ron Haselhorst of Richard Wolf Medical Instruments, a marketer of a Piezo acoustic shockwave machine. Mr. Haselhorst says an increasing number of pain management and chiropractic offices are offering shockwave therapy treatments in their practices because the equipment allows the professional therapist to produce positive results more quickly and efficiently.

Shockwave therapy has been effective for one-time treatment of strains and sprains as well as multiple treatments for chronic injuries. Mr. Haselhorst says shockwave therapy could become more popular in the United States as it becomes available for a wider range of patients.

8. Minimally invasive surgeries and robotic assistance.
Arguably, the biggest trend in orthopedics over the past few years has been minimally invasive surgeries. Recent technological developments have made it possible to perform a variety of different sports medicine procedures using minimally invasive techniques, which decreases the recovery time for the patients. "More of the advances are going to revolve around getting athletes back into the field with minimally invasive surgery," says Dr. Nicoletta. Robotic technology for used to assist physicians with minimally invasive knee surgery, such as MAKOplasty, has gained in popularity over the last year.

However, there isn't any proven data that computer assisted surgery leads to better outcomes, says Dr. Chang. "It is much better for precision in getting the tunnels in the right place, but that doesn't always mean there will be better results," he says. Using computer assistance often means the surgery takes longer and an experienced surgeon may not benefit from the technology. In fact, if the surgeon is very experienced, he or she might have a better understanding of performing the surgery in complicated cases, trumping the machine.

9. Diagnostics and image guidance.
Better MRI technology and new imaging methods are going to lead to new understandings and better diagnosis when treating sports medicine injuries, says Dr. Nicoletta. New studies show that MRI is able to pick up more subtle injuries, such as articular injuries in the knee, which allows physicians to be more proactive in their treatment. Ultrasound guided injections are being used to diagnose early injuries to the rotator cuff that are not visible on the x-rays. Some physicians have begun to use 3-D MRI imaging technology to preplan surgery and perform image-guided procedures, which will become more popular in the future, says Dr. Nicoletta.

"The advances in ultrasound guided treatment and MRI allows us to better understand sports medicine injuries and we can treat them sooner, which allows for improvement in outcomes," says Dr. Nicoletta.

10. Concussion management. Recent studies published in professional journals reveal that NFL players who sustain multiple head injuries are at an increased risk for developing behavioral disorders and degenerative conditions like Parkinson's and Alzheimer's. Additional research suggests some concussed athletes don't experience concussion symptoms and are at risk for sustaining another concussion before the first has healed. Rest is the only treatment currently approved for concussions, which means most sports medicine physicians and team organizations are focused on concussion prevention. "You're seeing a lot of talk about limiting helmet-to-helmet contact in football. You're hearing about problems arising from violent checking against the boards in hockey. Women's lacrosse athletes may now have to wear helmets and head gear to prevent injuries," says Dean Karahalios, MD, a neurosurgeon with the NorthShore Neurological Institute at NorthShore University HealthSystem in the Chicago area. "In terms of prevention, there will continue to be an increase in concussion awareness among players and trainer circles."

Several organizations are taking on the challenges associated with preventing concussions. Researchers with Cleveland Clinic and the Rawlings helmet company have partnered to develop new football helmets intended to decrease the impact of head trauma. Recent developments in assessment tools, such as the ImPACT testing, have made it easier for physicians to detect concussions among individual athletes and examine whether the injuries have fully healed before allowing the athlete back to his or her activity. Many athletic programs around the country are adopting the ImPACT testing, which requires each athlete to perform a series of cognitive and physical tests before the season. Athlets sustaining a hit to the head or suspected concussion are required to repeat the ImPACT testing and achieve baseline performance before returning to play. Several states are now requiring youth athletes to obtain a physician's written note before returning to play, which is a trend that could catch on in other regions of the country.

11. Increase in new sports medicine physicians. Recent trends show that there is an increasing number of students studying orthopedic surgery are seeking training in sports medicine. Sports medicine physicians have also been among the top-grossing orthopedic surgeons, making an average annual salary of $653,642, according to MGMA's 2010 Physician Compensation and Production Survey. The level of pay is only one reason why young surgeons are training in the field. "Sports medicine is a very attractive field and it has always generated interest in orthopedic surgeons coming out of training both because of the generalized field and the interest in sports medicine training," says Dr. Nicoletta.

One of the advantages to working in sports medicine is that the patients are often active, which means they are in good shape going into treatment and are willing to work hard to return to their activity. "I think that will continue to intensify as we continue to have advances and more exciting ways to treat injuries surgically and non-surgically," he says. An increase in sports medicine physicians, especially primary care and general sports medicine physicians, could help combat the increase in active older adults and new Medicaid patients who will need sports medicine services in the future.

Read other coverage on sports medicine:

- ACSM: Top 10 Trends in Sports Medicine


- 24 Orthopedic Practices With Great Sports Medicine Programs

- 3 Predictions on the Evolution of Sports Medicine

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