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)
.
Acute Tendon Tears
These require prompt referral < 1 wk
• Achilles• Patella• Distal Biceps
.