David B. Cohen, M.D. - Orthopaedic Surgery & Sports Medicine - Shoulder, Knee, and Elbow Specialist    
 
Shoulder Knee & Elbow Specialist, New Haven CT

In the News

Rate of injuries among youth soccer players doubled, new study finds
Source:
Science Daily

From 1990 through 2014, the number of soccer-related injuries treated in hospital emergency departments in the US each year increased by 78 percent and the yearly rate of injuries increased by 111 percent among youth 7-17 years of age, a new article reports.

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Study finds predictors for ACL injury are dissimilar between male and female athletes
Source:
Healio

Except for increased anterior-posterior knee laxity, results from this study indicated female athletes and male athletes were not similar with regard to predictors for first-time noncontact ACL injury.

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A look at factors correlated with scapular notching after reverse shoulder arthroplasty
Source:
Healio

At the American Academy of Orthopaedic Surgeons Annual Meeting, Eric Ricchetti, MD, discussed implant and patient-specific factors correlated with scapular notching following reverse shoulder arthroplasty. He noted increased range of motion caused more impingement events which lead to scapular notching.

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Malnourished patients had increased risk for short-term complications after TSA
Source:
Healio

Patients who were malnourished prior to total shoulder arthroplasty experienced a significantly increased risk for blood transfusion, longer hospital stay and death within 30 days of surgery, according to results of this retrospective database study.

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Why treating shoulder pain in baseball pitchers and other throwing athletes is so difficult
Source:
Science Daily

Despite increasing medical knowledge, treating shoulder pain in baseball pitchers and other throwing athletes remains one of the most challenging tasks in sports medicine.

“The results of treatment are not as predictable as the patient, family, trainer, coach and doctor would like to think,” according to an article in the journal Physical Medicine and Rehabilitation Clinics of North America.

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Imaging identifies cartilage regeneration in long-distance runners
Source:
Medical News Today

Using a mobile MRI truck, researchers followed runners for 4,500 kilometers through Europe to study the physical limits and adaptation of athletes over a 64-day period, according to a study presented today at the annual meeting of the Radiological Society of North America (RSNA).

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What Happens When You Crack Your Knuckles
Source:
Daily Rx News

Despite the wives' tales that tie cracking your knuckles to problems like arthritis, many habitual knuckle-crackers just can't help themselves. But do they really have anything to fear?

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Osteochondral autograft transplantation may offer higher rate of return to pre-injury athletics
Source:
Healio

Among patients who underwent cartilage repair of the knee, osteochondral autograft transplantation enabled a much higher rate of return to pre-injury athletics, according to results presented at the International Cartilage Repair Society Annual Meeting.

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Caregivers frequently unaware of safety guidelines for young baseball pitchers
Source:
Healio

Results of a survey presented at the American Academy of Orthopaedic Surgeons Annual Meeting indicated caregivers were frequently unaware of safety guidelines recommended for young baseball pitchers.

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An Injury Curveball for Young Pitchers
Source:
Daily Rx

The love of America's pastime might lead many young players to play as often and as hard as they can, sometimes for multiple teams. However, that might increase these players' risk of getting hurt.

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Female athletes at highest risk for first-time noncontact ACL tear
Source:
Healio

Although multiple factors influence first-time noncontact ACL injuries, female athletes are most at risk to sustain them, according to recently published data.

Researchers reviewed first-time noncontact ACL injury data from 320,719 collegiate athletes and 873,057 high school athletes between fall 2008 and spring 2012. Athlete exposure was determined retrospectively using team-reported schedule and roster data. Effects of competition level, sport and sex on ACL injury risk were estimated by Poisson regression.

Athlete incidence rate was 0.150 per 1,000 person-days among collegiate athletes and 0.061 per 1,000 person-days among high school athletes. When adjusted for differences in sport and gender, the researchers found college athletes were significantly more likely to sustain a first-time noncontact ACL injury than high school athletes.

Overall injury incidence rate was 0.112 in female athletes and 0.063 for males. When adjusted for sport and level of play, females were more than two times more likely than males to have a first-time noncontact ACL injury.

Among all athletes, rugby and soccer players ran the highest risk of these ACL injuries (2.23 and 1.77 times more likely, respectively), according to the researchers.

Disclosure: This work was supported by the National Institutes of Health (R01 AR050421) and the Department of Energy (SC00017).

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Study reveals shifting trends in the surgical treatment of SLAP lesions
Source:
Healio

A review of information from the American Board of Orthopaedic Surgery part II database indicates that the rate of SLAP repairs performed for both cases of isolated SLAP lesions and those undergoing concomitant rotator cuff repair has decreased, while the rates of biceps tenodesis and tenotomy for these cases have increased.

"Practice trends for orthopedic board candidates indicate that the proportion of SLAP repairs has decreased over time, with an increase in biceps tenodesis and tenotomy,” Brendan M. Patterson, MD, MPH, and his colleagues wrote in their study. “Increased patient age correlates with the likelihood of treatment with biceps tenodesis or tenotomy versus SLAP repair. "

Using the database, the investigators identified 8,963 cases treated for isolated SLAP lesions and 1,540 cases that underwent concomitant rotator cuff repair and treatment for SLAP lesions between 2002 and 2011. Mean patient age was 40.7 years.

Researchers reviewed surgical logs for the following procedures: SLAP repair, open or arthroscopic biceps tenodesis, biceps tenotomy, and arthroscopic rotator cuff repair with concomitant SLAP repair.

Patterson and colleagues found the proportion of SLAP repairs decreased from 69.3% to 44.8% for patients with isolated SLAP lesions. The proportion of biceps tenodesis for these cases increased from 1.9% to 18.8% and biceps tenotomy went from 0.4% to 1.7%. Similarly, the investigators found the proportion of SLAP repair decreased in cases undergoing concomitant rotator cuff repair (from 60.2% to 15.3%).

The proportion of biceps tenodesis or tenotomy for these cases increased from 6.0% to 28.0%. A subanalysis of biceps tenodesis showed that open procedures increased from 1.9% to 9.5% during the total study period, and arthroscopic biceps tenodesis increased in from 0.2% to 9.3% from 2007 to 2011.

Overall, investigators discovered a significant difference in the mean age of patients who had SLAP repair (37.1 years) compared with those who had biceps tenodesis (47.2 years) and biceps tenotomy (55.7 years).

Disclosure: This study was paid for by the University of North Carolina at Chapel Hill, Department of Orthopaedic Surgery, Sports Medicine Research Fund.

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Antibiotic cement during primary TKA may not decrease infection rates
Source:
Healio

Judicious risk-stratified usage of antibiotic cement during primary total knee arthroplasty may not decrease infection at 1 year, according to study results. Researchers retrospectively reviewed data for 3,292 patients who underwent primary total knee arthroplasty (TKA). Patients were grouped into cohorts based on whether their surgery involved plain or antibiotic cement, or if they were high-risk patients who received antibiotic cement, and infection rates were compared between the cohorts.

Study results showed a 30-day infection rate of 0.29% in cohort 1, 0.2% in cohort 2 and 0.13% in cohort 3.

Infection rates in all cohorts increased at all time points, with 6-month rates at 0.39% in cohort 1, 0.54% in cohort 2 and 0.38% in cohort 3, and 1-year rates at 0.78% in cohort 1, 0.61% in cohort 2 and 0.64% in cohort 3. However, no statistically significant between-group differences in infection rates were seen at any of the time intervals studied, according to the researchers.

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Early alteration after distal radius fracture casting not associated with loss of alignment
Source:
Healio

Although cast alteration after casting for distal radius fractures is common, early cast alteration was safe and not associated with loss of alignment, according to study results.

Researchers retrospectively reviewed patient records for 296 adult patients who presented with distal radius fracture and were treated with a below-elbow circumferential plaster cast at a tertiary care hospital from 2006 to 2009. Outcome measures included patient demographics, polytrauma at the time of injury, subspecialty of the physician performing the reduction and type of cast alteration.

The researchers used radiographs to assess initial fracture characteristics and secondary displacement of reduction over time, and an analysis was performed to identify predictive variables for the early cast alteration and determine the alterations’ effects on fracture alignment.

Study results showed 22.2% of patients underwent cast alteration during the early treatment, with splitting as the most common alteration performed, followed by application of new cast and cast trimming.

Upon stratifying by fracture classification, the researchers found patients with type A fractures had an alteration frequency of 23% compared with 22% in patients with type B fractures and 21% in patients with type C fractures.

Among patients treated by orthopedic residents, 22% had their cast altered compared with 21% of patients treated by emergency room physicians.

According to study results, 36% of patients with multiple injuries had their cast altered, whereas 21% of patients with isolated distal radius fractures had their cast altered.

No type of cast alteration was found to be significantly predictive of loss of fracture alignment at 2 or 6 weeks, according to the researchers.

Disclosure: The authors have no relevant financial disclosures.

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Multilayer compression therapy reduces ankle, hindfootedema more quickly
Source:
Healio

A faster reduction of ankle and hindfoot edema resulted from multilayer compression therapy and may be an alternative treatment for patients with ankle and hindfoot fractures, according to study results.

In a controlled, single-blinded study, researchers randomly assigned 58 patients with unilateral ankle or hindfoot fractures to a cold pack control group, a multilayer compression bandage group or an impulse compression group. Patients were analyzed according to the intention-to-treat principle. The study’s primary outcome was the reduction of edema as measured with the figure-of-eight-20 method.

Significant differences were seen in edema reduction between the bandage group and the control group both preoperatively and postoperatively, according to the researchers. In the control group, the researchers found a reduction in median preoperative edema of –2 mm, compared with –11 in the bandage group and –0.3 mm in the impulse compression group, after 2 days of intervention.

Median edema changes were +3.5 mm in the control group, –7.3 mm in the bandage group and +5 mm in the impulse compression group after 2 days postoperatively, according to the researchers.

The researchers concluded that although multilayer compression therapy appeared to be a viable alternative to treatment with ice, intermittent impulse compression applied without any extra compression from bandage or stockingette and without elevation during off-session periods was not.

Disclosure: See the study for a full list of all authors’ relevant financial disclosures.

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Similar clinical outcomes found with, without acromioplasty after rotator cuff repair
Source:
Healio

After rotator cuff repair, study results showed no difference in clinical outcomes with or without acromioplasty at 2 years postoperatively.

Researchers randomly assigned 114 patients undergoing arthroscopic repair of full-thickness rotator cuff tears into acromioplasty or non-acromioplasty groups. Along with physical examination, which included range of motion and dynamometer strength testing, the researchers collected the Simple Shoulder Test, American Shoulder and Elbow Surgeons, Constant, University of California — Los Angeles and SF-12 health assessment scores and recorded intraoperative data, including tear size, repair configuration and concomitant procedures.

The researchers reviewed preoperative imaging to classify the acromial morphologic type, acromial angle and lateral acromial angulation.

Overall, 95 patients were available for a minimum of 2-year follow-up. Study results showed no significant differences in baseline characteristics, including number of tendons torn, repair configuration, concomitant procedures and acromion type and angles. All functional outcome scores improved significantly from preoperatively to all follow-up time points in both groups.

Additionally, there were no significant differences in functional outcomes between the two groups or between patients with different acromial features at any time point, according to the researchers.

Disclosure: See the study for a full list of all authors’ relevant financial disclosures.

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Autografts may improve ACL reconstructions
Source:
Medical News Today

Anterior Cruciate Ligament (ACL) reconstructions occur more than 200,000 times a year, but the type of material used to create a new ligament may determine how long you stay in the game, say researchers who presented their work at the Annual Meeting of the American Orthopaedic Society of Sports Medicine (AOSSM).

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Identifying risk factors for ACL re-injury
Source:
Medical News Today

Re-tearing a repaired knee Anterior Cruciate Ligament (ACL) happens all too frequently, however a recent study being presented today at the American Orthopaedic Society for Sports Medicine's (AOSSM) Annual Meeting suggests that identification and patient education regarding modifiable risk factors may minimize the chance of a future ACL tear.

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Positive outcomes seen at long-term follow-up after meniscal repair
Source:
Healio

Arthroscopic meniscal repair was found to have a high probability of positive outcomes at long-term follow-up, according to a presenter here.

“Most patients did not have subsequent surgery until 5 years or greater following their initial repair,” Karen K. Briggs, MPH, MBA, said during her presentation at the American Orthopaedic Society for Sports Medicine Annual Meeting.

In the study, researchers analyzed 206 patients who underwent arthroscopic meniscal repair. Repair failure was defined by subsequent meniscal surgery (either re-repair or meiscectomy) or if the knee was converted to total knee arthroplasty (TKA).

Demographic data, SF12 physical component score and the mental component score, Lysholm score, WOMAC score, IKDC score, Tegner activity scale and patient satisfaction (1-10 scale) were all recorded. Average follow-up was approximately 14 years.

Overall, 64 knees were classified as failures (47 meniscectomies, 14 menicsal re-repairs, three TKAs). Average SF-12 physical component score was 54, and average mental component score was 54. The average Lysholm value at final follow-up was 86, average WOMAC value was 6 and the average IKDC value was 73, according to Briggs. Median Tegner activity scale value was 6, and median patient satisfaction score was 9.

Older patients did not experience an increase in failure of repair. —by Christian Ingram

Reference:Steadman JR. Paper #45.Presented at: American Orthopaedic Society for Sports Medicine Annual Meeting; July 10-13, 2014; Seattle.
Disclosure: The authors received research support from Smith & Nephew, Arthrex, Ossur and Siemens.

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High success rates seen for combined meniscal, ACL repair
Source:
Healio

Concurrent meniscal and ACL repair has shown high rates of success, according to a presenter here.

Researchers evaluated 235 patients from the Multicenter Orthopaedic Outcomes Network (MOON) who underwent both unilateral primary ACL reconstructions and concurrent meniscal repair between 2002 and 2004. Of the meniscal repairs, 154 were medial, 72 were lateral and nine underwent both.

Validated patient-oriented outcome data (KOOS, WOMAC) scores, Marx activity scores and IKDC scores were recorded at 2 and 6 years follow-up. Failure of meniscal repairs was determined by subsequent ipsilateral repair.

“This represents the largest cohort combining meniscus repair and ACL reconstruction follow-up for a minimum of 6 years,” Robert W. Westermann, MD, said during the American Orthopaedic Society for Sports Medicine Annual Meeting.

Overall, 86% of meniscal repairs were successful at 6-year follow-up; of these, 86.4% were medial meniscal repair, 86.1% were lateral meniscal repairs and 77.8% were in cases where both were repaired, according to Westermann.

Of the 33 repair failures, nine (27.3%) were related to revision ACL surgery. On average, medial meniscal repairs failed sooner than lateral repairs (2.1 years vs. 3.7 years).

KOOS Symptoms, KOOS Pain, KOOS KRQOL, WOMAC Pain, and IKDC values all improved significantly when comparing baseline scores to 6-year follow-up, according to Westermann. Marx Activity levels gradually declined from time of injury to 6-year follow-up. — by Christian Ingram

Reference:Westermann RW. Paper #44.Presented at: American Orthopaedic Society for Sports Medicine Annual Meeting; July 10-13, 2014; Seattle.
Disclosure:Westermann has no relevant financial disclosures.

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Bone-patellar tendon-bone ACL grafts show more tunnel motion than hamstring grafts
Source:
Healio

Patients with bone-patellar tendon-bone grafts have more tunnel motion rather than mid-substance stretch 6 weeks after ACL reconstruction when compared to patients with hamstring grafts, according to data presented at the American Orthopaedic Society for Sports Medicine Annual Meeting.

James N. Irvine, MD, and colleagues at the University of Pittsburgh prospectively studied 16 patients who had anatomic single-bundle ACL reconstruction done either with bone-patellar tendon-bone (BTB) grafts or hamstring grafts. Average patient age was 20 years, and both groups had identical tunnel locations, drilling and fixation. Data were available for 6 BTB patients and 6 hamstring patients.

The researchers embedded six 0.8-mm tantalum beads into the ACL grafts before implantation. Pairs of beads were placed within each bone tunnel and in the graft mid-substance. They obtained CT scans 6 weeks after surgery and used them to create 3-D femur and tibia bone models. Irvine and colleagues then fit cylindrical coordinate systems to the bone tunnels to assess tunnel motion and collected dynamic stereo X-ray images while patients walked and descended stairs. They defined graft-tunnel motion as the maximum displacement of the implanted beads along the bone tunnel axis after foot strike.

According to study results, both groups exhibited graft motion within the femoral and tibial tunnels, with more femoral tunnel graft motion seen in the BTB group during walking and stair descent. There was more BTB graft motion in the femoral tunnel than in the tibial tunnel.
For the hamstring grafts, researchers observed more graft motion in the tibial tunnel than in the femoral tunnel.

The researchers found no difference in knee kinematics between the grafts and no evidence of faster integration of BTB grafts over hamstring grafts. Furthermore, there was no detectable mid-substance strain in either group and no difference in knee kinematics, Irvine said.

“Quantitive MRI will be useful to further assess graft healing. Additional time points would be useful to better define rehabilitation protocols and return to sport,” he said.

A 1-year follow-up test is underway to see if the pattern reverses as graft-tunnel healing progresses. – by Kristine Houck, MA, ELS

Reference:Irvine JN.Paper #22.Presented at: American Orthopaedic Society for Sports Medicine Annual Meeting; July 10-13, 2014; Seattle.
Disclosure: Irvine has no relevant financial disclosures.

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Shoulder activity not associated with severity of atraumatic rotator cuff tear
Source:
Healio

Among patients with atraumatic rotator cuff tears, shoulder activity was not associated with severity of the tear, but was affected by patients’ age, sex and occupation, according to study results.

Researchers prospectively enrolled patients with an atraumatic rotator cuff tear on MRI in the Multicenter Orthopaedic Outcomes Network shoulder study of nonoperative treatment. Patients were asked to complete a previously validated shoulder activity scale; 434 patients completed the scale and were included in the analysis. Mean patient age was 62.7 years.

The researchers performed a regression analysis to assess the association of shoulder activity level to rotator cuff tear characteristics, including tendon involvement and traction, as well as patient factors such as age, sex, smoking and occupation.

Shoulder activity was not associated with severity of the rotator cuff tear, according to the researchers. However, shoulder activity was negatively associated with age and female sex. According to the regression model, 69-year-old patients with rotator cuff tears were 1.5 points less active on the 20-point scale vs. identical 56-year-old patients; female patients were 1.6 points less active vs. similar male patients. Occupation was also a significant predictor of shoulder activity level, with unemployed patients predicted to be 4.8 points less active compared with employed patients.

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Patients should wait at least six weeks to resume driving following shoulder replacement surgery
Source:
NewsMedical

More than 53,000 Americans have total shoulder joint replacement (SJR) surgery each year, and yet the effects of this surgery on a patient’s ability to safely drive a vehicle, and the appropriate recovery time before patients should return to driving, have yet to be determined.

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New probe could help determine severity of rotator-cuff injuries
Source:
MedicalXpress

A new ultrasound probe that has been developed at Clemson University could take some of the guesswork out of determining the severity of rotator-cuff injuries, making it easier for doctors to decide whether patients need surgery.

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Improving healing in Achilles tendon injuries by embedding stem cells inside sutures<
Source:
Medical News Today

Achilles tendon injuries are common for professional, collegiate and recreational athletes. These injuries are often treated surgically to reattach or repair the tendon if it has been torn. Patients have to keep their legs immobilized for a while after surgery before beginning their rehabilitation. Athletes may return to their activities sooner, but risk re-rupturing the tendon if it has not healed completely.

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82% of college football players return to field after ACL surgery, shows study
Source:
News Medical

High-level college football players frequently return to the field after an ACL reconstruction, according to research presented today at the American Orthopaedic Society for Sports Medicine's (AOSSM) Specialty Day. The study added to earlier research by exploring specific factors that affected return to play, including player standing on rosters and year in school.

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Early motion shows results comparable to immobilization after arthroscopic rotator cuff repair
Source:
Healio

In a 30-month follow-up of young patients who underwent arthroscopic rotator cuff repair, researchers found no significant differences in shoulder function between those who had early passive range of motion and patients who were immobilized.

“There is no apparent advantage or disadvantage of early passive range of motion compared with immobilization with regard to healing or functional outcome,” Jay D. Keener, MD, and colleagues from Washington University wrote in their abstract.

The investigators studied 124 patients younger than 65 years who underwent arthroscopic repair of full-thickness rotator cuff tears and were randomized to either an early range of motion rehabilitation process or to an immobilization group that had range of motion delayed for 6 weeks. The investigators evaluated the patients using the Visual Analog Scale (VAS) for pain, American Shoulder and Elbow Surgeons score, Simple Shoulder Test, relative Constant score and strength measurements. There were 114 patients available for final follow-up.

At 3 months postoperatively, the immobilization group had significantly better mean active range of motion into elevation and external rotation compared with the early motion cohort. “After 3 months, there were no significant differences in VAS pain score, active range-of-motion values, shoulder strength measures, or any of the functional scales between the groups at the time of the 6-month, 12-month, or final follow-up evaluation,” wrote Keener and colleagues wrote in their study.

Although the investigators’ research did not study patient satisfaction, “Immobilization did not appear to lead to greater risks of shoulder stiffness,” they wrote. There was also no difference in terms of tendon healing between groups.

“Either early passive motion or a period of early immobilization is equally safe and effective after surgical rotator cuff repair in this cohort,” the researchers wrote.

Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the 36 months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work.

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Secret to Fewer Doctor Office Visits After 70: Play High School Sports
Source:
Science Daily

Seventy year olds who don't frequently visit the doctor have something unexpected in common -- most played high school sports. They were active on a team over 50 years ago and are more likely to be active into their late 70s.

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A Little Exercise Goes a Long Way to Prevent Disease in Children
Source:
Science Daily

Studies conducted by the Appalachian State University Human Performance Laboratory at the NC Research Campus in Kannapolis, N.C., show that when children increase their level of physical activity, they experience positive health benefits quickly. Benefits include less body fat, increased muscular strength and reduced risk factors for major diseases like diabetes, cardiovascular disease and other metabolic and lifestyle-related disorders.

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Combating Sports-Related Concussions: New Device Accurately and Objectively Diagnoses Concussions from the Sidelines
Source:
Science daily

In the United States there are millions of sports-related concussions each year, but many go undiagnosed because for some athletes, the fear of being benched trumps the fear of permanent brain damage, and there is no objective test available to accurately diagnose concussions on the sidelines. Balance tests are a primary method used to detect concussion. The current means of scoring these tests relies on the skill of athletic trainers to visually determine whether or not a concussion has occurred.

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Rotator cuff tears
Source:
Medical Observer

This Update looks at the anatomy, assessment and management of rotator cuff tears.

The rotator cuff is a set of tendons that surround the humeral head and seat the head in the glenoid which in turn allows overhead function. They are crucial tendons and commonly injured. The most commonly injured of the four tendons is the supraspinatus, particularly, at its insertion into the greater tuberosity on the humeral head.

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Knee osteoarthritis risk unaffected by moderate exercise
Source:
Medical News Today

A new study suggests that the risk of middle-aged and older adults developing knee arthritis is unaffected by doing up to 150 minutes per week of moderate physical activity, the level recommended by the US government.

Knee arthritis leading cause of disability and joint pain Osteoarthritis occurs when the cartilage and underlying bone in a joint break down, leading to bony overgrowth, pain, swelling and stiffness.

The joints most affected are the knees, hips and those of the hands and spine. The condition, for which there is currently no cure, develops gradually, usually in the over-40s.

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David B Cohen MD, Orthopaedic Surgeon, New Haven CT
Dr. David Cohen, Knee Surgeon, New Haven Connecticut He is a Board-Certified Orthopaedic Surgeon...
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