American Medical Society for Sports Medicine

Ten Things Physicians and Patients Should Question

Released (1–5) April 5, 2014; Released (6–10) March 29, 2022

DOWNLOAD PDF

1. 1

   Avoid ordering a brain CT or brain MRI to evaluate an acute concussion unless thereare progressive neurological symptoms, focal neurological findings on exam or there is concern for a skull fracture.

   Concussion is a clinical diagnosis. Concussion is not associated with clinically relevant abnormalities on standard neuroimaging with CT or MRI. These studies should be ordered if more severe brain injury is suspected. CT is best utilized for skull fracture and intracranial bleeding, whereas MRI may be ordered for prolonged symptoms, worsening symptoms or other suspected structural pathology.

2. 2

   Avoid ordering an abdominal ultrasound examination routinely in athletes with infectious mononucleosis.

   Splenic enlargement is common in patients with infectious mononucleosis. The spleen is at increased risk for splenic rupture in the first 3–4 weeks of infection. This has led many clinicians to utilize ultrasound to determine if splenic enlargement is present. However, because individual splenic diameters vary greatly, comparing splenic size to population norms is not a valid method to assess splenic enlargement.

3. 3

   Don’t prescribe oral contraceptive pills as initial treatment for patients with amenorrhea or menstrual dysfunction due to female athlete triad (defined as low energy availability with or without disordered eating, menstrual dysfunction and low bone mineral density).

   The cause of female athlete triad is an imbalance between energy intake and energy expenditure that leads to menstrual dysfunction (abnormal or loss of periods) and low bone mineral density. Historically, some physicians have used oral contraceptive pills (OCPs) to regulate the menstrual cycle in this disorder. However, the underlying cause for the menstrual dysfunction is energy imbalance. Treatment includes increasing caloric intake and/or decreasing energy expenditure (exercise) to restore normal menses, which can take up to 12 months or longer. Additionally, OCPs do not increase bone density in females affected by the triad. By restoring menses, OCPs can mask energy imbalance and delay appropriate treatment. We recommend a multi-disciplinary approach to treatment that includes a physician, dietitian, mental health professional (when appropriate) and support from coaches, family members and friends.

4. 4

   Avoid ordering a knee MRI for a patient with anterior knee pain without mechanical symptoms or effusion unless the patient has not improved following completion of an appropriate functional rehabilitation program.

   The most common cause of anterior knee pain is patellofemoral pain syndrome. Magnetic resonance imaging (MRI) is rarely helpful in managing this syndrome. Treatment should focus on a guided exercise program to correct lumbopelvic and lower limb strength and flexibility imbalances. If pain persists, if there is recurrent swelling or if mechanical symptoms such as locking and painful clicking are present, and radiographs are non-diagnostic, an MRI may be useful.

5. 5

   Avoid recommending knee arthroscopy as initial/management for patients with degenerative meniscal tears and no mechanical symptoms.

   Degenerative meniscal tears may respond to non-operative treatments such as exercise to improve muscle strength, endurance and flexibility. Other treatment options include mild analgesics, anti-inflammatory medication, activity modification or corticosteroid injection. If mechanical symptoms such as locking, painful clicking or recurrent swelling are present, or if pain relief is not obtained after a trial of non-operative treatment, arthroscopy may be warranted. If significant osteoarthritis is also present, other surgical options should be considered.

6. 6

   Do not forget to routinely assess activity levels and recommend appropriate physical activity to your patients.

   Leading an active lifestyle has wide-ranging health benefits for people of all ages. Specifically, studies have shown a decrease in all-cause mortality associated with increasing levels of energy expenditure (Kcal/week). It has also been shown to decrease risk of coronary artery disease, diabetes, hypertension, many types of cancers, and a host of other medical conditions with strong, consistent epidemiologic evidence and moderately strong supporting evidence from clinical trials. Benefits on bone health and mental health have also been demonstrated. In the United States, cardiovascular disease alone accounts for an estimated $214 billion per year in healthcare expenses and causes $138 billion in lost productivity at work according to the Centers for Disease Control. Preventing cardiovascular disease, as well as other conditions, can potentially decrease both the use of healthcare resources and the associated cost.

   Practitioners should routinely assess physical activity levels and recommend safe and appropriate activity to patients. The potential risks associated with a well-designed exercise program that accounts for age, baseline fitness level and medical history/co-morbidities are low, and far exceeded by the potential benefits. Some studies have also shown that exercise prescriptions increase physical activity levels and quality of life

7. 7

   Do not order ankle or midfoot X-rays for patients older than 6 years old without positive criteria per the Ottawa ankle rules.

   Both children and adults commonly present to healthcare settings in the outpatient clinics, urgent care clinics and hospital emergency rooms with ankle and foot injuries. Multiple randomized control studies and meta-analyses have shown the high sensitivity of the Ottawa Ankle Rules (OAR) to rule out fractures when criteria are not met, and thus avoid the need for imaging in the acute setting. Unnecessary imaging increases healthcare costs, patient wait times, and radiation exposure. It should be noted that there is much less data for application of the OAR for pediatric patients under the age of 6, due to less ankle and midfoot injuries in this patient population as well as difficulty of children in this age group to walk independently.

8. 8

   Consider evaluating rotator cuff tears with ultrasound before ordering an MRI.

   Rotator cuff tears are one of the most common causes of shoulder pain. Determining rotator cuff integrity is pivotal in deciding between surgical and non-surgical management. The combination of clinical history, physical examination, and imaging studies is needed to confirm the diagnosis. Given its comparable diagnostic accuracy, low cost and convenience, high-frequency ultrasound may be considered prior to MRI, based on clinical determination via medical history, physical examination and review of relevant imaging, for the evaluation of rotator cuff tears. Furthermore, the cost of MRI and some contraindications, like the presence of metal-mounted devices, could make ultrasound a better, more accessible option in certain clinical scenarios. A clinician skilled in diagnostic ultrasound could decide not to obtain an MRI for a rotator cuff tear if the diagnosis is clear after obtaining a good medical history, completing an adequate physical exam and performing a good quality diagnostic ultrasound.

   Ultrasound of the rotator cuff should be done by an experienced provider at a center with appropriate diagnostic ultrasound equipment.

9. 9

   Do not cast or perform follow-up x-rays for isolated, non-displaced/non-angulated distal radius buckle fractures that do not involve the physis and which have an intact cortex in children.

   Distal radius buckle fractures are one of the most common wrist fractures in children. These fractures are inherently stable and have an excellent prognosis. As long as the following conditions are met, radius buckle fractures can be safely treated with a Velcro removable wrist splint for 3-4 weeks as long as:

   1. Cortex is intact.
   2. There are no fracture lines extending to the physis on any view.
   3. There is no angulation/displacement of the fracture.
   4. There are 2 or 3 inflection points seen in the cortex on either view which best represents the fracture.
   5. The parent can do a symptom check with instructions.

   Treating in a cast and repeating x-rays increases healthcare costs as well as radiation exposure for the patient. Parent satisfaction is also increased when these fractures are treated with a brace.

10. 10

    Do not delay initiation of early sub-threshold, symptom-limited aerobic exercise as rehabilitation for adolescents who have sustained an acute sport-related concussion.

    Concussions represent 70–90% of all traumatic brain injuries, creating an increasingly major and costly health concern. In adolescent athletes, sportrelated concussions (SRC) account for an estimated 2.2 million emergency department visits per year in the United States. The historic standard for treatment of SRC consists of physical and cognitive rest until symptoms resolve, followed by a stepwise gradual return to activity. However, the current consensus among experts is that there is insufficient evidence for prescribing complete physical and cognitive rest until asymptomatic after acute SRC. Moreover, unnecessary delays in activity initiation for athletes may have detrimental effects on physical fitness and mental health, leading to additional sub-specialist consultations and more extensive use of medical resources, driving up the cost. Thus, we recommend initiating early sub-threshold, symptom-limited aerobic exercise as rehabilitation for adolescents who have sustained an acute SRC, especially given the overwhelming amount of recent high-quality, data-driven evidence sufficiently demonstrating symptomatic improvement and decreased recovery time with this strategy.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

The American Medical Society for Sports Medicine (AMSSM) is proud to be a partner in the Choosing Wisely® campaign. Founded in 1991, AMSSM is a multi-disciplinary organization of 2,500 sports medicine physicians dedicated to education, research, advocacy and the care of athletes of all ages. The majority of AMSSM members are primary care physicians with fellowship training and added qualification in sports medicine who then combine their practice of sports medicine with their primary specialty. AMSSM includes members who specialize solely in non-surgical sports medicine and serve as team physicians at the youth level, NCAA, NFL, MLB, NBA, WNBA, MLS and NHL, as well as with the U.S. Olympic team. By nature of their training and experience, sports medicine physicians are ideally suited to provide comprehensive medical care for athletes, sports teams or active individuals who are simply looking to maintain a healthy lifestyle. This partnership with the Choosing Wisely campaign aligns with AMSSM’s dedication to providing the highest standard of comprehensive care of the athlete, while reducing unnecessary health care costs.

For more information or questions, please visit www.amssm.org.