Innovations That Will Drive Sports Medicine In 2019

By Dev Mishra, M.D., President, Sideline Sports Doc, Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • I see three innovations that are currently in use making huge advances in 2019. They are:
  • Increasing use of biologics in sports medicine injury treatment
  • An expanding range of options to treat knee arthritis in active adults
  • A growing role for algorithm based mobile assessments and telemedicine

It’s very easy to get caught up in moonshots, longshots, and fantasy in the world of medicine, but I believe there are three highly innovative technologies that will have an increasingly prominent role and impact sports medicine in 2019.

The first of these is increasing use of biologics in sports medicine injury treatment. Second is the rapidly expanding range of treatment options for active individuals with knee arthritis. And finally, I expect to see an exponential increase in telemedicine and mobile algorithms to provide initial injury guidance.

Let’s have a look at each of these areas.

I recently attended an instructional course on the use of Biologics in orthopedic sports medicine. The course was chaired by my colleagues and Sideline Sports Doc advisors Jason Dragoo M.D.and Brian Cole M.D.The overall theme of the course was that the world of biologic offerings for sports medicine injuries is exploding in terms of the types of treatments we can offer our patients.

In particular, look to see a huge increase in Platelet Rich Plasma (PRP) injections for many types of soft tissue injuries such as chronic tendonitis and muscle injuries. The last year has shown progress with outstanding scientific research into the exact formulations of PRP that work best for different conditions. Not all PRP is created equal; there are critical subtleties especially in the concentration of white blood cells and platelets that go into the different formulations.

Also expect to see a growing number of “stem cell” injections for sports medicine conditions. There is still some debate as to what exactly a stem cell is – which is why I have it in quotes – but current formulations use a person’s own bone marrow or subcutaneous fat, and then purify the tissue for use in the same person. The science lags our experience with PRP but expect to see an expanding role for stem cell treatments, for sure.

New Treatments For Knee Arthritis In Active Individuals

The best way to treat pain and functional limitation for active people in their 40s – 60s remains challenging. Most of these folks have arthritis that’s significant enough to cause them problems but not severe enough to require a total joint replacement. This is where we have an expanding roster of new treatments.

In the last year we’ve seen the approval of an ultra long-lasting cortisone injectable, and increasing evidence that PRP can be effectively used in some types of knee arthritis. The formulations of PRP used in knee arthritis are different than those used in soft tissue problems. Additionally, the stem cell injections mentioned above will likely have a more prominent role in selected cases, and there are also amniotic fluid injections coming into clinical practice.

These technologies will offer new avenues of hope for the huge population of active adults with moderate knee arthritis.

The Move Away From In-Person Initial Advice For Sports Injuries

 This prediction is a bit tough for me, as I’m in a profession that may face some attrition due to the technological advances around us.

In the early 20thcentury doctors routinely made house calls. Those days are long gone. Next to disappear: the initial face to face interactions for many common sports injuries.

At Sideline Sports Doc the algorithm that powers the decision trees in our online courses were developed into a mobile app (Good To Go) that allows an athlete or a parent of an athlete to make an initial triage decision anywhere, in less than 3 minutes. We believe the algorithm can be adapted to any number of conditions.

Outside the realm of sports medicine, I believe care will increasingly be delivered in a hybrid real world-virtual world model. There are multiple companies successfully developing telemedicine networks, artificial intelligence engines, and mobile technologies (including wearables) that have the potential to radically alter the patient-physician interaction.

The time it takes for appointments (including the hassles of traveling to the office, waiting for the appointment, etc.) will drop substantially. The convenience of advice from your home, office, or playing field are compelling.Logo

As I’m trained in the traditional way of orthopedic practice there’s a big part of me that looks at the move away from in-person advice with dread. But when viewed from the patient standpoint I can easily see this becoming a major trend in 2019 and beyond. These innovations, available here and now, are going to be big parts of the sports medicine toolkit in the coming years.

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Using The SAFE Method™ to address Youth Sports Injuries

Dr. Brian Cole and Steve Kashul talk with Dr. Dev Mishra about the origin of Sideline Sports Doc, who is using the service and the value of a coach certification program. Dr. Mishra founded Sideline Sports Doc in 2010. The idea behind the company is simple: is there a way to teach non-medically trained coaches, parents, and athletes a simple method that allows them to recognize common sports injuries and make reasonable decisions about what to do next?

What is Sideline Sports Doc?

Every year the number of young children, adolescents and adults participating in sports activity increases, and unfortunately so do the number of injuries. Sideline Sports Doc develops injury recognition courses and technology solutions that help governing bodies, teams, coaches, parents and weekend warriors better understand how to manage injuries.

The course content is based on The SAFE Method™ that teaches you how to recognize a mild injury, a moderate injury, or a severe injury.  The courses do not to teach you how to diagnose and provide the final treatment for an injury.  Leave that to the professionals, such as a physician or an athletic trainer.


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Why I Like The King-Devick Concussion Tool

By Dev K. Mishra, M.D., President, Sideline Sports Doc, Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • The King Devick test is an easy, fast, and reliable objective assessment tool used as part of a concussion assessment program
  • The test involves rapid number naming on an iPad screen and can be used by non-medically trained individuals as well as medical personnel
  • We find it to be a very useful tool and use it often with our young athletes

I really like the King Devick rapid number naming test as part of a comprehensive concussion assessment program. We find it to be easy, fast, reliable, and with a large amount of independent scientific studies vouching for its validity. At the high schools I work with we use the King Devick in our preseason concussion baseline assessment and then use it as a part of our comprehensive evaluation for in-game concussions. I’d recommend you consider using it too. (Neither I, nor Sideline Sports Doc have any financial relationship with the company).

The test is performed on an iPad (there is a paper version available but you may need to contact the company directly for details on this), and involves the individual reading out loud a series of numbers that are shown at irregular intervals on the screen. The test is timed. The method tests the athlete’s ability to concentrate as well as the eye movements. We obtain a pre-season healthy baseline and then perform the test immediately after a suspected concussion on-field. Any increases in time post-injury compared to the baseline are suggestive of a concussion.

Concussion assessment involves evaluation of several areas and at least so far, there is no single perfect tool to definitively provide a sideline concussion diagnosis. A skilled athletic trainer or physician will assess how the injury occurred, check the athlete for concussion symptoms, and then perform a number of tests to assess cognitive function, memory, and balance. We use the King Devick as one component of the evaluation.

Our practical experience shows that the test is well accepted by the young athletes, and it’s difficult to “game” the system. We emphasize the importance of proper baseline testing to the athlete and have found very few who intentionally take a long time to do the baseline test. Plus there are well established ranges for “normal” and if an athlete deviates from the normal range we investigate further.

As we head into fall sports seasons for schools and leagues I’d like to remind everyone of some basic safety principles. First, make sure you spend some time on preventive planning!  If you’re a club or league be sure to have an emergency action plan and practice it in advance.

Make sure your coaches are properly trained in injury recognition, especially for the common injuries specific to your sport as well as concussion recognition. Hire an ATC for tournaments, or for your club if you can afford that. Pay very close attention to field equipment conditions (e.g. goal post properly secured). And finally, I’d strongly recommend an AED kept at a central location.


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Getting Strong Without Getting Hurt

By Dev K. Mishra, M.D., President, Sideline Sports Doc. Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Blood flow restriction training with B Strong straps allows for strength gains with very low resistance loads
  • The low loads mean that a person with joint conditions or recent surgery can maintain and gain strength without causing joint pain or risking a surgical repair
  • This is a real game-changer in the world of strength training with safe, natural methods

Many injured athletes and other patients I see need to get stronger in order to improve their function or performance. But for many of these folks getting strong through traditional resistance based strength training might lead to pain, or be dangerous after surgery. I wrote a few weeks back about a technique called blood flow restriction training, in which strength gains are made through very low load resistance. I believe there is great benefit for athletes with painful conditions, or rehab after surgery.

Common scenarios would be: a young athlete with patellofemoral syndrome who has a hard time gaining strength because the exercises increase knee cap pain; an older athlete with knee arthritis who increases pain with resistance training; or anyone after ACL surgery where incorrect or overly aggressive strengthening could harm the surgery result.

I spoke recently with Dr. James Stray-Gundersen, co-founder of B Strong and team physician with the U.S. Olympic teams. Dr. Stray-Gundersen emphasizes that the use of the resistance straps changes the body’s natural response to exercise and allows for increased circulation of our own internally produced healing hormones such as HGH and many others. He explains there are two key aspects for the athlete with an impairment such as knee pain, or anyone who has had surgery:

  1. The injured area is able to achieve strength gains with very low loads, which drastically reduces any potential joint soreness
  2. In a joint that’s had recent surgery the straps minimize atrophy in the surgical limb and at the same time allow safe exercise for the uninvolved limbs

He gave further detail:

“Perhaps the biggest thing B Strong training does is mitigate disuse atrophy that occurs when a person has to stop their normal activities due to injury or operation.  B Strong allows maintenance of training stress despite the setback of the injury, when standard training is impossible or would delay healing or damage the repair.  We want to exercise as much of the body’s muscle mass as possible, without risking further injury to the healing injury or operation.

So, for example, with an ACL repair or a total hip, I would start upper body B Strong on the 1st day post op.  I am doing this for 2 main reasons.  First, to mitigate atrophy in the rest of the body and second, to get as big of a systemic effect as possible to optimize healing resources.  Then usually by Day 3 post op, I am doing both upper body and lower body B Strong (taking care to not put a band across a fresh incision).

On the operated leg, it may only be gentle, non-weight bearing, ROM exercises with the bands on, but it is exercise.  Ideally we do daily sessions with patients and progress the exercises as tolerated, always cognizant of not disturbing the healing injury or operation.  Exercises are always easy enough that they are done with proper form.  Results are remarkable and come remarkably fast.

So in summary, B Strong training in the rehab setting is exercise mainly for the uninjured parts of the body, while making sure we don’t disturb the healing injury or operation. This approaches accelerates the patient’s return to their previous activities compared to the current standard of care.Logo

B Strong BFR Training is really a “doable” form of exercise in people with the special consideration of a musculoskeletal injury or operation.”

In my opinion this is a real game changer. If you’re trying to maintain or increase strength and having a hard time because the exercises cause pain, or if you’ve had recent surgery I’d strongly encourage you to discuss B Strong resistance training with your doctor and physical therapist.

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