Sports MedicineBoard Review

Beth Raleigh, DOHunterdon Family Medicine

at Phillips Barber

February 23, 2019

Head

• Head & face injuries most common• Concussion

– No same day RTP– 2nd impact syndrome in children– Normal conventional imaging– Needs evaluation & clearance by

primary care provider– Return to Learn

Head

• Concussion– Return to Learn – once athletes are

asymptomatic with life & brain work, can consider RTP exercise protocol

– RTP exercise protocol is a graded exertional protocol

– Final Clearance by primary care provider

Neck

• Spurling’s– Cervical Radiculopathy– Foraminal impingement maneuver

• Stingers/Burners– Stretch injury to brachial plexus– Usually upper trunk - C5-6– Unilateral– Resolves in a few minutes– Common in Football

Upper Extremity - Shoulder

• Anterior Dislocation– Xray image– Tx: prompt relocation

• Clavicle Fracture– Midclavicular, min displacement– Tx: Sling 2-6 wks

• Rotator Cuff impingement– Neer & Hawkins tests

Shoulder Dislocation

• Anterior ≥ 95%

– Traumatic injury in Abducted & ER

position usual MOI

– Bimodal incidence

• Young male athletes – high impact

• Older deconditioned women - fall

• Posterior – seizure/electrocution

Shoulder Dislocation

• Clinical appearance– Arm held in Ab/ER, loss of normal

Deltoid contour• Diagnosis with X-ray• Normal

– AP images = humeral head overlaps with glenoid – see convex lens shape

– Y scapular – ball centered in Y or slingshot

Shoulder X-rays APNormal Anterior Dislocation

Shoulder X-rays Y scapularNormal Anterior Dislocation

Clavicle Fractures

• Fall on Shoulder• Fall off Bike, MVA• Zones of fracture

– Group 1 = Middle 1/3 ~ 69%– Group 2 = Distal 1/3 ~ 28%– Group 3 = Prox 1/3 ~ 3%

Clavicle Fractures

Treatment• Group 1 = Middle 1/3

– If minimal or nondisplaced• Nonsurgical in sling until healed

– Clinical healing = NTTP, pain free motion– Radiographic = callus seen on XR

– If significant displacement, shortening, comminuted or patient preference

• Refer for orthopedic consultation

Shoulder SeparationAC joint injury

• Typically from fall onto or hit to top of shoulder - FB, wrestling, hockey, etc.

• Pain, swelling, deformity over AC joint • Cross over test positive• X-ray to confirm diagnosis of

separation and rule out fracture• Sling until x-ray results come in

Shoulder SeparationAC joint injury

• Type I – AC partially torn, XR = WNL– Tx: Conservative = sling

• Type II – AC completely torn, CC partially torn or intact, XR = Wide AC– Tx: Conservative = sling

• Type III – Both AC & CC torn, XR = wide AC & CC– Tx: Refer for opinion

Adhesive Capsulitis

• Chronic condition – Causes:

• Immobility• Inflammatory event – bursitis/tendonitis• Medical – DM, Thyroid Dz, RA, Parkinson’s

• Sx: Stiffness, night pain, loss of function in ADL’s

• PE: Significant loss of Glenohumeral both AROM & PROM

Adhesive Capsulitis• Treatment:

– Physical therapy, stretching– Steroid injection may allow for

progress to normal motion– Often many months of physical therapy– Recovery 6 mo. – 2yrs– If all else fails…

• Manipulation under anesthesia (MUA)• Surgery

Little Leaguer’s Shoulder

Proximal humeral epiphysitis

– Pitcher’s injury– Age 11-16– Dx: X-rays bilateral; will see widening– Tx: Rest, PT- scapular stabilizers,

core, kinetic chain, pitch counts, pitching coach

Shoulder Tests

• Special Tests– Hawkins – impingement – Neer’s –impingement – Empty Can – supraspinatus injury/pain– Obrien’s & Crank test – labral injury – Apprehension – shoulder dislocation– Speed’s & Yergason’s - biceps

Elbow - Peds

• Nursemaid’s Elbow– Most common children’s elbow injury– Subluxation of Radial head– Toddler age– Hand held & yank/pull– Holds arm bent & close to side– Tx: Hyperpronation method

Elbow - Peds

• Little Leaguers Elbow– Medial Epicondyle Apophysitis

– MC young pitcher’s injury

– Age 9-14

– Progressive pain with throwing

– No trauma/injury history

– TTP medial elbow

– Tx: Rest 4-6 wks, Pitching coach to correct mechanics

Lateral Epicondylitis

• aka Tennis elbow– Pain/Inflammation of wrist extensor

origin at lateral epicondyle– Pain w/ resisted wrist & 3rd finger

extension– Can become chronic– Tx: Stretch, strength, PT, Ice, NSAID’s,

braces– Tx: CS injection = ST relief, no LT

benefit

Olecranon BursitisMost common superficial bursitis

• Acute bursitis – may benefit from aspiration & CS injection for diagnosis & symptom relief

• Septic suspected – Aspiration for diagnosis – send for fluid analysis

• Chronic from microtrauma – not likely to benefit from aspiration/injection

• Risk of iatrogenic septic bursitis

Khoadee, M. Common Superficial Bursitis. AFP 2017:95(4)224-231

Carpal Tunnel Syndrome– Median nerve irritation/compression at

transverse carpal ligament– Sx: pain & paresthesia into thumb & 1st 3

fingers, radial side 4th tip– Long term can cause thenar atrophy &

permanent nerve damage– PE: + Phalen’s, + Tinel’s– Diagnostics: Electrodiagnostic

Carpal Tunnel Syndrome• Treatment

– Mild = intermittent paresthesia/symptoms• CT night splint• Steroid injection• Oral steroids effective, but SE risk

– Moderate – severe ® refer• May need surgical decompression

Kothari, M. Carpal Tunnel Syndrome. Post, TW,ed.In: UpToDate. Waltham, MA: UpToDate Inc. (Accessed on February 8, 2019)

Upper Extremity - Wrist

• Dequervain’s syndrome– Stenosing tenosynovitis of APL

(abductor pollicis longus) & EPB (extensor pollicis brevis)

– + Finklesteins test– Tx: thumb spica splint,

corticosteroid injection

Upper Extremity - Wrist

• Scaphoid Fracture – After FOOSH injury– Snuffbox TTP– Initial XR often negative– Proximal 1/3 fractures = high risk of

nonunion or AVN– Thumb spica cast (non-displaced)– Refer generally

Upper Extremity – Hand

• Mallet Finger

– Cannot Actively Extend DIP joint

– Distal Phalanx held in flexion

– Rupture of Ext digitorum tendon(s)

– Stax splint (DIP joint only) x 6-8 wkDO NOT REMOVE AT ALL

If splint is removed, the clock restarts

High level of noncompliance

Upper Extremity – Hand

• Jersey Finger– Contact sport injury, grabs a jersey– Rupture of FDP – Cannot actively flex @DIP especially

against resistance– REFER to hand surgeon– Surgical reattachment

Trigger Finger

• Stenosing Flexor Tenosynovitis– Tendon thickening at the A1 pully– Fingers can get locked in flexion– Often patients wake up with this– Can be due to specific work/activities– Acute: Trial of splinting, activity

modification & NSAID’s– Persistent: Corticosteroid injection

can provide long term relief

Upper Extremity – Hand

• Boxer’s Fracture – 5th MC neck– EtOH often involved– Male, punching a wall– XR images– Tx: No displacement & no/slight

angulation = Ulnar gutter splint 3-4 wk– Tx: 30°+ volar angulation or

displacement = surgical pinning

Hand Arthritis

Finger Arthritis Characteristics1. Rheumatoid - MCP, PIP

– Erosions, periarticular osteoporosis

2. Psoriatic – DIP– Erosions, dactylitis = sausage digits (pencil

in cup)

3. Osteoarthritis – DIP, PIP– Joint space narrowing, productive changes,

osteophytes, subchondral sclerosis/cysts

Chest/Ribs

• Commotio cordis– MOI - Blunt trauma to chest wall– Baseball – boys & teens– Triggers VT or Vfib– High fatality rate– Early defibrillation can be life saving

Adolescent Idiopathic Scoliosis

• Definition: Cobb angle> 10°

• Standing scoliosis XR to diagnose

• Females more likely to need treatment

• Mild < 20°

– PE w/ height & Tanner staging q3-6mo

– Monitor for progression –serial XR

• Cobb >20°

– Refer generally unless postmenarchalor low growth potential

Lumbar spine – LBP Red Flags

• Night pain – wakes out of sleep• Pain out of proportion to exam• Cancer history• Neurologic deficit• Systemic/B symptoms

– Fever, weight loss, night sweats• Age > 50, Age < 18• Osteoporosis history (compression fracture)

Low Back Pain

• Lumbar Stenosis– Older age– Worse with Extension

• Lumbar Disc Herniation– Younger, middle age– Acute onset, sometimes next am– +/- Popping sound– Pain worse w/ Flexion, sitting

Lumbar spine

• Spondylolysis– Stork test– XR – scotty dog

• Spondylolisthesis– Shifting can occur with bilateral –lysis

• If significant can require surgery– Degenerative type (DDD)

Lumbar Spine – Spondy…• SpondyloLYSIS – fracture of pars interarticularis region

– Usually occur during adolescent/teenage years– May be Unilateral or Bilateral – 85% at L5– Many asymptomatic– Some are stress related or sport specific – repetitive/extreme

posterior loading or back bending• Runners, gymnasts

• Diagnosis – history, exam (stork test), Imaging – XR = OBLIQUES to see…

• “Collar on Scotty dog” – Xray sign• MRI or CT scan will be definitive if Xray unclear

Lumbar Spine – Spondylolysis

Low Back Pain Acute & Subacute

• Clinical guideline for Acute, Subacute & chronic LBP from ACP 2017

• Acute (<4wks) & Subacute (4-12wks) Treatment Recommendations– Nonpharmacologic

• Heat• Massage• Acupuncture• Spinal manipulation – Osteopathic or Chiropractic

Low Back Pain Acute & Subacute

• If Pharmacologic treatment is desired– NSAIDS– SMR – skeletal muscle relaxers

• No Bed Rest!

Chronic LBP - Treatment

• Chronic LBP is defined as > 3 months– Exercise– Multidisciplinary rehabilitation– Acupuncture– Mindfulness-based stress reduction– Yoga, tai chi, CBT, progressive relaxation,

biofeedback, etc– Spinal manipulation

Chronic LBP - Treatment

• If inadequate response to all of the above…– NSAIDS = 1st line– Duloxetine (Cymbalta) = 2nd line– Tramadol = 2nd line

• Clinicians should only consider opioids as an option for those who have failed all of the above AND if the potential benefits > risks after a realistic review of the potential harms & benefits

– Ann Intern Med 2017;166:514-530

Cauda Equina Syndrome

• Massive posterior disc herniation may cause critical compression on all descending nerve roots

• Urinary Retention = #1 MC sign• Loss of Motor control of Lower Extremities• Loss of Bowel +/- bladder control• Surgical emergency • MRI diagnosis

Lower Extremity - Pelvis• Iliac Crest Apophysitis

– One of the last growth plates to close– Mid to late teens– Female runners

• Avulsion Fractures• Ischial tuberosity - hamstrings• ASIS - Sartorius• AIIS – Rectus femoris• Pubic bone – adductors, gracilis

Posterior Hip PainPATHOLOGY

• Gluteus Medius – Pain/strain from overuse & weakness– Muscle/tendon tear - Trendelenburg

• Piriformis Syndrome– 11% of population will have all or a portion of the

sciatic nerve running through the Piriformis muscle

– Piriformis spasm can mimic Radicular symptoms but may be more diffuse/generalized, not as dermatomal

– OMT can help!

Lower Extremity

Red Flags• Night pain – wakes out of sleep

• Pain out of proportion to exam

• Cancer history

• Systemic/B symptoms

– Fever, weight loss, night sweats

• Unable to Bear Weight

• Long-term or multiple courses of oral steroids

• Buckling or Locking

HipPediatrics

• Transient Synovitis– Acute onset, holds hip in FABER

– Fever +/-, Labs – WNL (CBC, ESR,CRP)

– Tx: NSAIDS

• Osteonecrosis of femoral head– Insidious onset

– Legg-Calve-Perthes disease = idiopathic, ages 3-12

– Sickle Cell Disease

– Refer

HipPediatrics

• SCFE = slipped capital femoral epiphysis– Obese, Pre-pubertal usually 11-14– MC insidious onset limp & pain w/ weight

bearing or exercise, occas acute– Sx: Hip, thigh or knee pain, limb held in ER– PE: PROM limited & painful– Dx: X-ray– Tx: NWB on crutches until seen by Ortho

• Surgical pinning

Hip Pain

• REMEMBER HIP PAIN can present

as Knee pain!

• Hip –

– Femoroacetabular (CAM)

impingement

• Insidious onset w/ active patients,

• Pain w/ pivot

• PROM - pain w/ FADIR

Hip Pain• Avascular necrosis = osteonecrosis

– Insidious onset, weight bearing pain– h/o previous trauma, oral steroids,

EtOH, HIV, Connective tissue disease, Caisson’s (the bends)

– Exam: pain w/ all PROM• Osteoarthritis

– Older age– Exam: pain w/ FABER, PROM flexion

>90, IR

Knee Pain - PedsNon-traumatic

Osgood Schlatter’s =Tibial tubercle apophysitis

• Boys 12-15, Girls 8-12, growth spurt• May accompany patellar tendonopathy

• Dx: Clinical - exquisite TTP @ Tib tub, Xraysshow fragmentation, lifting off at Tib Tubercle

• Tx: Relative rest, avoid exacerbating activities, ice, stretch & strengthen quads/hamstrings

• Athletes will grow out of this

Knee Pain - PedsNon-traumatic

Sinding –Larsen-Johansson Syndrome –Inferior patella pole apophysitis

• Running & Jumping sports

• Recent Growth Spurt, Age 10-14

• Dx: TTP inf patella pole, XRay may show widening/fragmentation of growth plate and rule out other conditions

• Tx: Avoid offending activities, physical therapy, ice, stretch & strengthen hamstrings & quads

Knee PainNon-traumatic

• Patellofemoral syndrome– Anterior Knee pain, Running– Lateral patellar tracking – Weak VMO, hip abductors– Tight ITBand, ↑ Q angle– Tx: relative rest, PT

• Osteoarthritis– Tx: Active Exercise & stretching, PT

Posterior Knee Pain

PATHOLOGY• Meniscus – posterior horn injury• Popliteal Cyst = Baker’s cyst =

semimembranosus bursitis (symptom of an intraarticular process)

• Popliteal Artery aneurysm– Pulsatile mass in popliteal fossa

Knee Bursitis• Bursitis

• Pes Anserine – more likely in overweight ♀

• Prepatellar – Housemaid’s• Usually chronic• high level of infection after drainage• If acute drain if required for

diagnosis/treatment• Many other bursa in the knee

Knee - Meniscus Injury

• Meniscus Injury– MOI - Plant & twist common– Dx: Thessaly Test

• stand, flex 20° & twistMcMurray’s

– Tx: Conservative - RICE, PT– Surgical – if significant locking or

buckling, if MRI reveals bucket handle tear, if fails conservative care 2-3 mo

Knee ACL Injury

• ACL tear – most nontraumatic– Often hear/feel a pop upon landing

from a jump

– Early effusion common may be bloody

Dx: Lachman = best test, Ant drawer

Tx: Typically surgical for young & active

Less active, > 30 yo usually conservative

Knee ACL Injury

• ACL tear – Usually associated with concomitant

injuries– “Unhappy Triad”

• ACL tear• Medial meniscus injury• MCL injury

Knee Effusion

• Aspiration – indications– Diagnosis

• Septic knee – if you think this – patient should be in the Emergency room

• Gout or Pseudogout• Bloody effusion – suggests ACL tear or other

acute intraarticular derangement/fracture• Lyme – if Lyme arthritis is present, blood test

would be universally positive

Knee Aspiration• Joint fluid characteristics

– Crystals• Gout - monosodium urate crystals

– Needle shaped, negative Birefringent• Pseudogout – calcium pyrophosphate

disease– Rhomboid/polygon, positive birefringent– Associated with Chondrocalcinosis (knee

usually)

MTSS = Medial tibial stress syndrome

• Aka “shin splints”– Usually young, untrained runners– Too much mileage too fast– Associated w/ Arch Pronation– Posterior tibialis tendon traction from

pronation pulls on medial tibia– If Bone repair lags behind breakdown,

this can progress to Stress Fracture

Tibia Stress Fracture

• Tibial Stress Fracture– Runner w/ increased mileage– Exam: single leg hop, tuning fork,

edema– Dx: X-ray initially may be negative

(repeat 3 wk)– Tx: Distal fractures = Walking boot – Proximial tibia or anterior “dreaded

black line” = NWB ortho referral

Ankle SprainsInversion Injury

• ATFL – MC sprained• CFL – next likely to be injured• PTFL - last

Eversion Injury • Deltoid ligament

Dorsiflexion/Eversion Injury • High ankle/syndesmotic sprain• Tibiofibular ligaments

Ottowa Ankle rules• Ankle XR needed

– Pain in malleolar zone AND• Unable to take 4 steps immed & in ER/office• +TTP post edge or Tip of malleolus

• Foot XR needed– Pain in midfoot zone AND

• Unable to take 4 steps immed & in ER/office• +TTP base of 5th MT or Navicular

Achilles• Achilles Tendinopathy

– Chronic– Tx: Eccentric strengthening of Gastroc

& soleus• Achilles Tear

– Acute – refer for surgical opinion immediately

– Chronic – management varies

Plantar Fasciitis• Plantar fasciitis

– MCC of heel pain in adults– Pain at medial/plantar origin on calcaneus– RF: ↑weight, long standing, poor footwear– Tx: Eccentric calf stretches similar to

Achilles tx, arch supports, +/- NSAID’s, night splint, injection

Lower Extremity – Sever’s• Calcaneal Apophysitis = Sever’s disease

– Age 9-13– Growth plate inflammation from overuse, Achilles traction– Tx: PT, stretch, relative rest, (No US)

Lower Extremity – Fractures• Jones Fracture – acute fx of proximal

diaphysis of 5th Metatarsal– Active pts: Surgical referral– Inactive: NWB in cast 6 wk & repeat XR for

healing• Phalanx Fractures

– 2-5 Stiff-soled shoe & Buddy taping – 1st – May need surgical pinning

• Refer Displaced or > 25% of joint involvement

Medical Conditions

• Gout – Acutely painful, warm, swollen joint– Usually 1st toe or knee– Dx: Joint fluid aspiration,

• Labs: +/- uric acid ↑ , CBC - WNL– Treatment options

• NSAID’s, indomethacin (avoid in CKD)• Colchicine (Colcrys) (avoid in CKD)• Prednisone

Medical Conditions

• Polymyalgia Rheumatica– Pain & stiffness bilateral Shoulders, arms,

hips, other joints– Inflammatory condition– ESR elevated– Tx: Prednisone 15 mg daily (10-20), slow

taper

Medical Conditions

• Ankylosing spondylitis– Insidious onset non-traumatic LBP– Inflammatory condition– Pain improves with exercise & activity– Morning stiffness– Pain worse at night

Diagnosis - Labs

• Blood work – Lyme disease– Rheumatologic workup

• CBC, CMP, ESR, CRP, ANA, RF– Gout – uric acid– STD’s

Preparticipation PE• Do about 6 weeks prior to sport• AHA 14 point screening guidelines should be

used• Universal screening with a 12 lead ECG not

recommended• Athletes with SBP<160 & DBP <100 should

not be restricted from sport• No screening blood & urine tests

Mirabelli, MH, Devine, MJ. The Preparticipation Sports Evaluation. Am Fam Physician. 2015 Sep 1;92(5):371-376.

Preparticipation PE

• Most common cause of sudden death in younger athletes in this country (<35yo) is HCM = hypertrophic cardiomyopathy– Murmur - harsh crescendo-decrescendo systolic

@ LSB & apex increases with Valsalva or standing from squat

• MCC of sudden death in older athletes (>35yo) is Coronary artery disease

. Pelliccia,A, Link,M. Athletes: Overview of sudden cardiac death risk and sport participation. Post TW,ed. UpToDate .Waltham, MA.

(Accessed on February 14, 2019)

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Acute Tendon Tears

These require prompt referral < 1 wk

• Achilles• Patella• Distal Biceps

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