Welcome to another episode of Game Plan! It has been a while since we have done one of these Game Plan episodes so to quickly review: These episodes are specifically designed for patients. They are designed to hopefully answer some of the questions you have about the most common sports medicine conditions, injury prevention and treatment options.

Today we’re talking about pickleball – the fastest growing sport in the United States. From 2019- 2021, the number of pickleball players increased from 3.3 to 4.8 million. The reason for the growth of the sport is likely multifactorial, including that it encompasses a wide variety of age ranges, it is easy to understand and it is inexpensive to play. However, with this steady growth has come a corresponding linear rise in pickleball injuries. And these injuries are not inexpensive, costing between 250 to 500 million dollars in 2023 alone.

Pickleball is a paddle sport that takes aspects from tennis, badminton, and ping-pong. Now, we were going to try to explain the pickleball rules here, and how it differs from other racquet sports. But, USA Pickleball has a really nice 5-minute video on their website (usapickleball.org) that quickly summarizes the basic rules. If you are interested in learning more about this game, definitely check out their website. It should be noted that the rules and scoring system are currently variable. But as more competitions arise, more standardization to the game will likely follow, as is the trend with most sports.

Today, we’re reviewing an article published in the November 2024 issue of the yellow journal titled “Pickleball: A Standard Review of Injury Prevalence and Prevention in a Rapidly Growing Sport.” This study compiled data from retrospective studies containing emergency department data and case reports of specific injuries sustained while playing pickleball. The authors also utilized a customized survey to capture outpatient data of current pickleball players seen in outpatient orthopedic facilities and at local pickleball events.

On each of these mini episodes, we chat about a new article or new surgical technique in the field of sports medicine. We’ll give you our quick take on the most recent data and how this data will be impacting our practice.

Today, we’re talking about graft choice for anterior cruciate ligament reconstruction, and specifically how that impacts psychological readiness to return to play. Now, we’ve spoken extensively about ACL injury on this podcast.

On our first ever episode with Dr. Mary Mulcahey was two-part segment all about ACL tears. Since then, we have gone on to discuss risks factors for ACL tears, ACL reconstruction, augmentation with lateral extra-articular tenodesis, revision ACL surgery and more! We also did an entire Game Plan episode on ACL graft choice and an Overtime episode “update” on ACL graft choice – the latter is episode #81 if you want to check it out.

We also touched upon psychological readiness to return to play after ACL reconstruction in episode #16. Musculoskeletal injuries, in particular ACL injuries, can take a tremendous psychological toll on our athletes. Depression, a common experience for injured athletes, has been associated with worse patient- reported outcomes, higher levels of pain, and increased rates of postop complications.

Unfortunately, caring for the mental side of the injured athlete remains a huge gap in our field of orthopedics and sports medicine. For this reason, Catherine and her colleague Emily Perrin created The Unbroken Athlete – a resource containing comprehensive mental and physical programs for athletes to enhance their recovery journey and performance. Catherine will speak a bit more about this during the episode.

Our paper today is titled “Association Between Autograft Choice and Psychological Readiness to Return to Sport After ACL Reconstruction.” This level 3 retrospective cohort study was performed at the Mayo Clinic in Arizona. It sought to evaluate the relationship between an athlete psychological readiness to return to sport, as defined by the ACL-RSI score, and autograft choice – either quadriceps tendon, hamstring tendon or bone-patellar-tendon-bone.

Today, we’re talking about the use of tranexamic acid or “TXA” for rotator cuff repair surgery. First, what is TXA? If you’re not an arthroplasty surgeon or a traumatologist, you may not be as familiar with this medication. TXA is drug that inhibits the enzymatic breakdown of fibrin blood clots, also known as fibrinolysis. By doing this, TXA stabilizes the thrombi, or blood clots, and thus decreases bleeding. TXA was originally developed to treat postpartum hemorrhage but its use has evolved over the years. It is now often used perioperatively in the setting of elective surgery to reduce blood loss, blood transfusions, ecchymosis, and hematoma formation.

In the field of orthopedics, use of TXA has traditionally been limited to big open surgeries where large volume blood loss is a concern, such as total joint replacement, fracture fixation and spine procedures. However, sports medicine procedures that rely extensively on visual clarity of the surgical field, such as knee and shoulder arthroscopy, can also greatly benefit from the use of TXA. By lessening intraoperative bleeding, TXA may result in better visualization of the surgical field, potentially decreasing operative time and subsequent postoperative swelling and pain. That is the clinical question that our paper today aimed to investigate. The article that we are reviewing is titled “Tranexamic Acid for Rotator Cuff Repair: A Systematic Review and Meta-analysis of Randomized Controlled Trials.” 

Today, we’re talking about postoperative rehabilitation after combined medial patellofemoral ligament reconstruction and tibial tubercle osteotomy to treat recurrent patellar instability.

As we’ve spoken about before on this show, literature to guide postop recovery after orthopedic surgery is lacking. Often times, we’re using our experience and the opinions of our colleagues and mentors to determine how to best rehab patients after surgery, rather than concrete data. It is critical to progress patients weightbearing, range of motion and strengthening appropriately.

So, it’s great when we see a high-level prospective randomized study come out that compares different rehabilitation strategies. Our paper today is titled “Early Postoperative Rapid Rehabilitation Yields More Favorable Short-Term Outcomes in Patients Undergoing Patellar Realignment Surgery for Recurrent Patellar Dislocation.”

We get lots of questions from our patients and our listeners each week. And they’re great questions, so rather than responding individually we thought we’d do these mini episodes where highlight some of the best questions and our responses. So, let’s get started!

Today’s Ask The Sports Docs is going to focus on a question we get asked a lot: What can I take supplement-wise to improve my healing and outcome after an orthopedic injury or surgery?

Pentadecapeptide BPC 157 enhances the growth hormone receptor expression in tendon fibroblasts

Injectable Therapeutic Peptides-An Adjunct to Regenerative Medicine and Sports Performance?

The role of vitamin D in shoulder health: a comprehensive
review of its impact on rotator cuff tears and surgical results

Happy New Year from The Sports Docs Podcast! 🎆

As we reflect on an incredible year of growth for our podcast, we’d like to take a moment to thank our amazing listeners, guests and supporters for making this podcast such a success! 

Our podcast has been downloaded in over 60 countries, is in the top 25% of @buzzsprout podcasts and is again ranked in the top sports medicine podcasts 📈

🎙️ We are very excited to see what 2025 has in store!

Happy New Year from The Sports Docs Podcast! 🎆

As we reflect on an incredible year of growth for our podcast, we’d like to take a moment to thank our amazing listeners, guests and supporters for making this podcast such a success! 

Our podcast has been downloaded in over 60 countries, is in the top 25% of @buzzsprout podcasts and is again ranked in the top sports medicine podcasts 📈

🎙️ We are very excited to see what 2025 has in store!

Our conversation picks back up with an article published in the December 2020 issue of Current Reviews in Musculoskeletal Medicine titled “Surgical Management of Massive Irreparable Cuff Tears: Superior Capsular Reconstruction.” Authored by our guest today, this review article summarizes the biomechanical properties and functional outcomes of superior capsular reconstruction or “SCR” for treatment of massive irreparable rotator cuff tears. The authors report that SCR decreases superior translation and subacromial contact pressure. Glenoid fixation is maximized with three anchors, while margin convergence to any remaining rotator cuff – particularly posterior – improves stability. Patient selection is key, with the ideal patient being younger than 70 and a healthy nonsmoker with an irreparable posterior cuff tear in the absence of glenohumeral arthritis and a functioning or repairable subscapularis. 

We finish up our discussion today with the publication titled “Latissimus dorsi transfer or lower trapezius transfer: a treatment algorithm for irreparable posterosuperior rotator cuff tears muscles transfers in posterosuperior rotator cuff tears.” Laurent Lafosse and team compared two tendon transfer options for irreparable posterior-superior rotator cuff tears with rotational deficiency – the latissimus dorsi transfer and the lower trapezius transfer.  They found that active motion, pain scores and function were improved in both groups with a low failure and revision rate.  The authors suggest that lower trapezius transfer better restores external rotation at the side while latissimus dorsi transfer may be a better option for restoration of external rotation and abduction.

On today’s episode we’re focusing on challenging rotator cuff pathology with Dr. Patrick Denard, an orthopedic shoulder surgeon at the Oregon Shoulder Institute. We have some great articles for you that contribute well to our conversation on the treatment options for massive reparable, as well as irreparable, rotator cuff injuries. As always, links to all of the papers that we discuss on this show can be found on our podcast website – www.thesportsdocspod.com

We’ll start off our discussion today with an expert opinion article from the July 2022 issue of Arthroscopy titled “Graft Augmentation of Repairable Rotator Cuff Tears: An Algorithmic Approach Based on Healing Rates.” Authored by our guest today, this article provides an algorithm for tissue augmentation of rotator cuff repairs based on the current available evidence regarding rotator cuff healing. The authors recommend using a Rotator Cuff Healing Index or “ROHI” cutoff of greater than or equal to 7 to select for the use of tissue augmentation, as the healing rate is 66% at 6 points but decreases substantially to 38% at 7 points.

Then, from the May 2019 issue of AJSM, we review an article titled “Rotator Cuff Matrix Augmentation and Interposition: A Systematic Review and Meta-analysis.” The authors concluded that graft augmentation provided significantly lower retear rates and higher ASES scores compared with cuff repair alone. With regards to graft choice for augmentation, the highest rates of healing, as demonstrated by repair integrity on imaging, were shown for allograft at 82% compared to xenograft at 68%. Nonaugmented repairs had a healing rate of only 49%.

We finish up our discussion today with the publication titled “Preoperative Nutrition Impacts Retear Rate After Arthroscopic Rotator Cuff Repair.” This level III retrospective study published in the August issue of JBJS this year, sought to determine the relationship between preoperative nutritional status, using the Geriatric Nutritional Risk Index or “GNRI”, and rotator cuff retears after arthroscopic repair in patients 65 years of age and older. The authors found that poor pre-op nutrition, as exhibited by a GNRI less than 103, was an independent risk factor for a cuff retear at 2 years post-op. 

We are joined today by Dr. Patrick Denard, a board-certified orthopedic shoulder surgeon and Director of the Oregon Shoulder Institute. He is also the Director of the Oregon Shoulder Fellowship and Associate Professor of Orthopedic Surgery at Washington Status University School of Medicine. Dr. Denard is the Chairman and Founder of the Pinnacle Shoulder meeting and a reviewer for the Journal of Shoulder and Elbow surgery. He has published and lectured extensively on the topic of rotator cuff pathology, so we are very excited to have him join our discussion today.

In this episode, we’re going to continue our discussion with Dr. Aaron Krych and focus on surgical advancements to address meniscus extrusion and optimize postoperative outcomes for patients.

Our conversation picks back up with an article published last month in Arthroscopy Techniques titled “Arthroscopic Centralization of the Extruded Meniscus With Posterior Root Tear: A Technique Using Meniscotibial Ligament Fixation.”  Most meniscus centralization techniques involved anchoring the meniscus body directly to the tibia, which can limit the normal anatomic motion of the meniscus. Dr. Krych and his team described a novel technique for meniscus centralization that maintains natural meniscal motion by utilizing the meniscotibial ligaments to centralize the meniscus body.

Then, from the May 2024 issue of Arthroscopy, we review an article titled “Satisfactory Clinical Outcome, Complications, and Provisional Results of Meniscus Centralization with Medial Meniscus Root Repair for the Extruded Medial Meniscus at Mean 2-Year Follow-Up.” This case series concluded that patients undergoing medial meniscus root repair with meniscus centralization demonstrated significant improvements in pain, function, satisfaction and quality of life.  Additionally, there was no evidence of significant arthritic progression on postoperative imaging.  No patients underwent revision meniscus surgery or total knee arthroplasty.