Management of Common Problems in Sports Medicine Cindy J. Chang, - - PDF document

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Cindy J. Chang, M.D.

Clinical Professor, Primary Care Sports Medicine

• Depts. of Orthopaedics and Family & Community Medicine

Past President, American Medical Society for Sports Medicine Board of Trustees, American College of Sports Medicine

2019 UCSF Primary Care Medicine

Principles and Practice Management of Common Problems in Sports Medicine Disclosure

▪ I have no conflict of

interest in relation to this presentation

▪ Ossur Americas:

independent lectures on

• steoarthritis

▪ NeuroSlam: scientific

advisor

▪ Agency for Student

Health Research: medical advisory board

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Objective

▪ Review common

problems in sports medicine

▪ Understand basic

anatomy of the musculoskeletal system and its clinical correlation to injuries

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History

(MS OLDCARTS vs OPQRST)

▪ Mechanism ▪ Symptoms

▪ Onset (O) – date of injury ▪ Location – point to where the pain is ▪ Duration – acute or chronic ▪ Character (Q) – burning, sharp, dull, achy ▪ Aggravating/Alleviating (P) – provokes/palliates ▪ Radiation (R) – come from or go anywhere else ▪ Timing (T) – constant, at night, with activity ▪ Severity (S) – grade pain

https://meded.ucsd.edu/clinicalmed/history.htm

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Case - Elbow Pain

▪ Your patient is a 36 yo female recreational tennis player with

elbow pain radiating down the posterior aspect of her forearm that has increased over the past two days. She recently began playing tennis on a USTA team that practices nightly.

▪ She has no medical problems. She takes a combination oral

• contraceptive. Family history is noncontributory. She does not

use tobacco, alcohol, or recreational drugs.

▪ She is afebrile with normal vital signs. Examination reveals

tenderness distal to the lateral epicondyle, with pain increased with wrist extension against resistance. She has increased pain with resisted supination.

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Case - Elbow Pain

Which of the following is most appropriate for this patient?

A.

Opioid analgesics

B.

Corticosteroid injection

C.

Counterforce bracing

D.

Extracorporeal shock wave therapy

E.

Strength training

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Elbow Anatomy Review

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Elbow XR Review

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Elbow Anatomy Review

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Elbow Anatomy Review

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Elbow Anatomy Review

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Elbow Pain – Dx: Lateral epicondylitis

“tennis elbow”

▪ No single treatment is completely effective

• Counterforce bracing relieves pain
• Strength training, exercise, stretching all decrease pain

▪ RICE: rest, elevation, compression, and elevation ▪ PMM: protection, medication and modalities (physical therapy) ▪ NSAIDs + watchful waiting better than CS injections ▪ CS injection better than PT at 6 wks, worse at 12 wks ▪ PT less pain and better fxn than CS inj or NSAIDs ▪ ECSWT no significant benefit

http://www.aafp.org/afp/2000/0201/p691.html http://emedicine.medscape.com/article/96969-medication#4 http://www.ucdenver.edu/academics/colleges/medicalschool/departments/familymed/education/fellowship/sportsmedf ellow/Documents/MS%20exam.pdf

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Elbow Pain – Diff Dx

▪ If mechanical symptoms

(locking, catching): r/o intraarticular pathology

▪ If neurological

symptoms (weakness, paresthesia); r/o nerve entrapment syndromes

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Elbow Pain – Diff Dx

▪ If neurological symptoms (weakness, paresthesia); r/o nerve

entrapment syndromes

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Case – Hand Weakness and Numbness

▪ A 31-year-old female gymnastics

instructor presents to your clinic with a complaint of right-hand weakness and numbness.

▪ She also works as a receptionist part-

time and states that her symptoms are worst at the end of her workday.

▪ On physical examination, there is a loss

• f sensation along the palmar aspect of

her thumb and first two digits. You note atrophy of her thenar eminence as well.

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Case – Hand Weakness and Numbness

The nerve implicated in her symptoms innervates which of the following muscles?

A.

Flexor digitorum superficialis

B.

Adductor pollicis

C.

Extensor digitorum

D.

Abductor pollicis longus

E.

Flexor carpi ulnaris

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Wrist/Hand Anatomy Review

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Wrist/Hand Anatomy Review

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Wrist/Hand Anatomy Review

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Wrist/Hand Anatomy Review

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Case – Hand Weakness and Numbness

The nerve implicated in her symptoms innervates which of the following muscles?

A.

Flexor digitorum superficialis

B.

Adductor pollicis

C.

Extensor digitorum

D.

Abductor pollicis longus

E.

Flexor carpi ulnaris

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Hand Weakness and Numbness – Dx: Carpal Tunnel Syndrome

▪ Your patient is presenting with carpal

tunnel syndrome, which affects the median nerve. It is caused by compression of the nerve by the flexor retinaculum at the palmar surface of the hand.

▪ Symptoms of carpal tunnel syndrome

are explained by the distal innervation

• f the nerve. It supplies sensation to

the palmar aspect of the thumb and adjacent 2 radial digits.

Moore, KL, et. Al; Clinically Oriented Anatomy. Lippincott, Williams, and Wilkins (2014). Philadelphia, PA.

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Hand Weakness and Numbness – Dx: Carpal Tunnel Syndrome

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Case – Wrist Pain after a Fall

▪ A 15-year-old boy presents to the emergency room for wrist

pain and swelling after a skateboarding accident. He broke his fall by landing on his wrist while the hand was in an

• utstretched or hyperextended position (FOOSH).

▪ On physical exam, his wrist is swollen more on the radial

side, and there is point tenderness on palpation of the anatomical snuffbox. He also hurts over the distal radius.

▪ The following x-ray image depicts which of the following

injuries resulting from this fall?

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Case – Wrist Pain after a Fall

A.

Scapholunate ligament injury

B.

Scaphoid fracture

C.

Triquetrum fracture

D.

TFCC tear

E.

Salter-Harris Type 1 fracture distal radius

F.

Radial head fracture

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Case – Wrist Pain after a Fall

Scapholunate ligament sprain

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Case – Wrist Pain after a Fall

Scaphoid fracture

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Case – Wrist Pain after a Fall

Triquetrum fracture

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Case – Wrist Pain after a Fall

Triangular FibroCartilage Complex tear

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Case – Wrist Pain after a Fall

Salter-Harris Type 1 fracture distal radius

▪

I – S = Straight across. Fracture of the cartilage of the physis (growth plate)

▪

II – A = Away from joint. The fracture is through and into the metaphysis, or Away from the joint.

▪

III – L = Leading to joint. The fracture is through and into the epiphysis, Leading to the joint.

▪

IV – TE = Through Everything. The fracture is through the metaphysis, physis, and epiphysis.

▪

V – R = Rammed (crushed). The physis has been crushed.

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Case – Wrist Pain after a Fall…check other joints!

Radial head fracture

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Case – Shoulder Dislocation

▪ A 20-year-old right-hand-dominant man

presented to the Emergency Department following a traumatic dislocation of his right shoulder that was self-reduced when

• surfing. Physical exam revealed an intact

axillary nerve with intact neurovascular status distally.

▪ Prior to presenting to your office, he had

dislocated two more times. A family friend was able to get him an MRI and he brings in the CD but you are still waiting for the faxed report. He comes to you for advice as his family physician.

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Case – Shoulder Dislocation

▪ What do you think will be the next best step in management? A.

Shoulder immobilizer and serial radiographs

B.

Bankart repair for surgical stabilization

C.

Surgical repair of a rotator cuff tear

D.

Physical therapy

E.

Learn how to become left handed

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Review of Shoulder Anatomy

▪ Layers

• Bony articulations (4)
• Static stabilizers

▪ Bones, ligaments, capsule,

labrum

• Dynamic stabilizers

▪ Scapular

stabilizers/rotators

▪ Rotator cuff muscles

• Bursa

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Shoulder Anatomy Review

Bony Articulations

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Shoulder Anatomy Review

Bony Articulations

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Shoulder Anatomy Review

Static Stabilizers

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Shoulder Anatomy Review

Static Stabilizers

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Shoulder Anatomy Review

Dynamic Stabilizers

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Shoulder Anatomy Review

Dynamic Stabilizers

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Shoulder Anatomy Review

Scapular Motion

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Shoulder Anatomy Review

Dynamic Stabilizers

▪ Rotator Cuff

• Supraspinatus
• Infraspinatus
• Teres minor
• Subscapularis

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Shoulder Anatomy Review

Dynamic Stabilizers ▪ Rotator Cuff

• Supraspinatus
• Infraspinatus
• Teres minor
• Subscapularis
• Subscapularis
• Supraspinatus
• Infraspinatus
• Teres minor

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Shoulder Anatomy Review

Bursa

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Case – Shoulder Dislocation

• B. Bankart repair

▪ Your 20 yo patient likely has a Bankart lesion in the setting of

a first time traumatic dislocation and now resultant instability

• f the glenohumeral joint due to the Bankart lesion.

▪ This requires surgical stabilization. ▪ A Bankart lesion may involve only the labrum or the labrum

plus a bony portion of the glenoid (bony Bankart).

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Possible Xray Findings

Hill Sachs Lesion – compression fracture of posterior humerus Bony Bankart Lesion – Avulsion fracture of glenoid 46

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Case – Shoulder Dislocation

▪ Labral-only lesions are most commonly repaired via an

arthroscopic stabilization procedure where the labrum is fixed back to the glenoid. Bony Bankart lesions may be addressed with open reduction and internal fixation with concomitant labral stabilization.

▪ <1% of RC tears occur in those < 20 yo ▪ There is a 40 to 60% incidence in patients > 40 years old ▪ Physical therapy will help strengthen the dynamic stabilizers.

However, there is a >90% recurrence if < 20 years old; only 14% recurrence if > 40 yrs old

Minagawa et al J Orthop 2013, Familiari et al ICJR 2014

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Case – Shoulder Pain

▪ 55 yo RHD female with onset of right shoulder

pain one year ago when playing tennis

▪ Had been “getting along” with it and

controlling symptoms but began to notice gradual loss of motion despite ice and NSAIDs

▪ Now presenting with pain all the time,

including night pain, with inability to sleep on shoulder due to pain

▪ She has had to buy new bras that clasp in

front

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Case – Shoulder Pain

What is your next step with your patient?

• A. Refer to PT if her ROM doesn’t improve with an aggressive

HEP at 1 mo F/U

• B. Control other comorbid conditions like HTN and

hyperlipidemia that predispose her to this problem

• A. Refer her to ortho for surgical manipulation under anesthesia
• B. Cortisone injection
• C. None of the above

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Case: Shoulder Pain

Adhesive Capsulitis

▪ Spontaneous, gradual onset of

shoulder stiffness and pain caused by tightening of joint capsule

▪ 70% female, 40-60 yoa ▪ Comorbid conditions include

diabetes, hypothyroid dz, RA

▪ Can occur after shoulder

immobilized or subconscious restricted motion after minor injury

• r ???

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Case: Shoulder Pain

Adhesive Capsulitis

▪ IR/ADDuction first to go

and last to come back

▪ Scapular substitution ▪ End range pain ▪ Disuse atrophy

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Natural History of Adhesive Capsulitis

▪ 0-3 months “gradual onset” - painful ▪ 2-9 months “ freezing” ▪ 4-12 months “ frozen” ▪ 5-26 months “thawing” ▪ Usually self-limited

“The art of

medicine consists of amusing the patient while nature cures the disease.”

• Voltaire

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Hannafin & Chiaia, Clin Orthop Rel Res, 2000

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Treatment of Adhesive Capsulitis

▪ Pain management (+/- sling) ▪ Education and reassurance ▪ Active home stretching

program

▪ Physical Therapy ▪ Oral NSAIDs (or steroids) ▪ Glenohumeral injection-

capsular distension

▪ Rarely needs surgery

(examination/manipulation under anesthesia or arthroscopic lysis of adhesions)

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Steroid injection?

▪ RCT showed intraarticular steroid injection provided

better pain relief in the first 8 weeks than NSAIDs.

▪ However, no difference seen in range of motion or

pain after 12 weeks

▪ Results similar to other non-controlled studies

Ranalletta M at al., Am J Sports Med, 2016

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Case – Ankle injury

▪ 16 yo female playing in basketball game

and turned her ankle inwards after a rebound when she came down on another foot

▪ Felt a pop; was unable to bear weight ▪ Immediate swelling on the outside and

front of ankle

▪ Able to limp into your exam room the next

day; points to her lateral ankle as the area of most pain

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Case – Ankle injury

Which is the following is an indication to order X-Rays?

• A. Feeling or hearing a pop
• B. Inability to walk for 4 steps immediately after the injury
• C. Any bruising along the lateral and/or medial malleolus
• D. Tenderness on palpation along posterior edge of

medial malleolus

• E. Numbness around the area of swelling

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Case – Ankle injury

Which is the following is an indication to order X-Rays?

• A. Feeling or hearing a pop
• B. Inability to walk for 4 steps immediately after the injury
• C. Any bruising along the lateral and/or medial malleolus
• D. Tenderness on palpation along posterior edge of

medial malleolus

• E. Numbness around the area of swelling

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Ankle and Foot Anatomy- Bones

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Ankle and Foot Anatomy- Ligaments

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Ankle and Foot Anatomy- Anterior

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Ankle and Foot Anatomy-Lateral

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Ankle and Foot Anatomy-Medial

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Ankle and Foot Anatomy-Posterior

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Case – Ankle injury

Ottawa Ankle and Foot Rules

▪ Inability to weight bear immediately and in the

emergency / office (4 steps)

▪ Bone tenderness at the posterior edge of the medial or

lateral malleolus (Obtain Ankle Series)

▪ Bone tenderness over the navicular or base of the fifth

metatarsal (Obtain Foot Series) Sens 97%, Spec 31-63%, NPV 99%, PPV <20%

Bachmann LM et al BMJ 2003

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Ottawa Ankle and Foot Rules

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Case – Foot Injury

▪ 45 yo female at the climbing gym, slipped

and lost her footing and landed awkwardly from ~4 feet

▪ Could bear weight but painful to push off.

R foot became more swollen than L

▪ Went to urgent care and told x-rays

normal, stay off feet for weekend, given crutches

▪ Comes to see you on Monday as still hurts

to walk

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Case – Foot Injury

Of the following, what is the most important question to ask?

A.

How many times a day have you been icing?

B.

Were you lying down or standing for your X-rays?

C.

Have you been keeping it wrapped in a compression type of bandage?

D.

Would you feel more comfortable in a walking boot?

E.

Are you having pain when driving?

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Case #2 – Foot Injury

Lisfranc ligament sprain

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Case – Ankle injury

▪ A 24-year-old professional athlete

presents to you with acute-onset right ankle pain and an inability to bear weight. You note significant edema and ecchymosis of the affected ankle.

▪ She states she had a similar

injury to her left years ago. Xrays were already obtained, with left ankle for comparison since she reported the prior injury. You decide to take a look at the xrays first before examining her.

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Case – Ankle injury

What is your diagnosis?

A.

grade 1 ankle sprain

B.

grade 2 ankle sprain

• C. grade 3 ankle sprain
• D. bimalleolar ankle fracture

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Normal Ankle X-Ray

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Evaluate entire fibula

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Case – Ankle injury

Grade 3 ankle sprain

▪ Grade 1 injury involves ligamentous

stretching without grossly evident tearing or joint instability.

▪ Grade 2 injury involves a partial tear of

a ligament with moderate joint instability; it is often accompanied by significant localized swelling and pain.

▪ Grade 3 injury involves a complete

tear of a ligament with marked joint instability and severe edema and ecchymosis.

Rose NG, Green TJ. Ankle and foot. In: Walls R, et al, eds. Rosen’s Emergency Medicine: Concepts and Clinical

• Practice. 9th ed., 2018:634-658.e3.

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Case – Ankle/Foot Injury

▪ 34 yo male, enjoys walking and hiking,

recently joined his work softball league

▪ First game of the season and hit a grounder;

while sprinting to first base, he felt a rock hit the back of his lower leg and he stumbled and fell. His teammates heard a pop. Needed assistance to get to the bench

▪ Iced, elevated, ACE wrap and NSAID ▪ He could walk as long as he kept the ankle

stiff; wore his hiking boots to come see you

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Case – Ankle Injury

What is the most likely injury based on his history?

A.

Anterior cruciate ligament (ACL) tear

B.

Achilles tendon tear

C.

Posterior tibialis tendon tear

D.

Calf tear

E.

Plantar fasciitis tear

F.

B and C

• G. B and D

H.

B and E

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Case – Ankle Injury

Achilles tendon tear and Calf tear

Thompson test

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Case – Ankle Injury

Posterior tibialis tendon tear Too

Too many toes sign

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Case – Knee Injury

▪ 40 yo female joined a gym in January with her competitive

sister-in-law

▪ Began working with a personal trainer and they started a

program of Olympic lifting (squatting, cleans) and plyometrics (box jumps)

▪ After 2 weeks began having left knee pain after workouts

but continued training

▪ Now seeing you 2 weeks later because now it hurts during

training and even with walking, especially on the stairs

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Case – Knee Injury

What is the Least likely diagnosis?

A.

Patellofemoral syndrome

B.

Patellar tendinitis

C.

Pes anserine bursitis

D.

MCL sprain

E.

ITB syndrome

F.

Hamstring strain

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Patellofemoral Pain

▪ Will point to kneecap

region

▪ Pain associated with

• running, lunging, squats
• sitting for prolonged period
• going down stairs (may be

worse than up stairs)

▪ Soft tissue swelling often

described as puffiness

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Patellofemoral Pain

▪ Thomas test to evaluate tight hip

flexors, quads, ITB

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Patellofemoral Pain

▪ Positive patellar

compression test

▪ Pain on palp of medial facet

• f patella

▪ Increased patellar mobility

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Patellofemoral Pain

▪ Double and Single Leg Squat to

evaluate for weak quads, gluts

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Patellar Tendinitis

▪ Pain with

• resisted knee extension
• resisted straight leg raise
• single leg squat

▪ May have swelling at

inferior pole of the patella

▪ Tenderness at prox patellar

tendon

▪ Osgood Schlatters

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Pes Anserine Bursitis

▪ Primary flexors of the knee ▪ Protects knee against rotatory

and valgus stress

▪ Pain often acute ▪ Can occur with sports and

exercise

▪ Can also occur in sedentary

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Iliotibial Band Syndrome

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Hamstring Strain

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Case – Knee Pain

▪ 65 yo male with h/o medial meniscectomy R knee 20 yrs ago ▪ Reports moderate pain medial knee and general swelling

since hiking last weekend

▪ Denies locking and instability, no AM stiffness ▪ On your exam, he has moderate effusion, but no warmth. There

is crepitus with range of motion. He is tender at the medial joint line and above/below medial joint line on the medial femoral condyle and medial tibial plateau. McMurrays testing is negative, but knee feels tight with squatting. You don’t find any ligamentous laxity

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Case – Knee Pain

What do you recommend at this time?

A.

Refer to an ortho surgeon to consult on knee replacement surgery

B.

Order an MRI of the knee to evaluate need for surgical intervention

A.

Refer to an orthopedic surgeon for surgical debridement and lavage (“clean it up”)

A.

Perform a cortisone injection to help with the pain and swelling

B.

Refer to physical therapy and encourage weight loss

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What is OA?

What parts of the knee joint are affected?

Disease of the entire synovial joint and multifactorial, including joint degeneration, intermittent inflammation, and peripheral neuropathy

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How do you classify severity of Knee OA?

▪ Kellgren and Lawrence System for classification of knee OA

Kellgren and Lawrence, Ann Rheum Dis 1957

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How do you classify severity of Knee OA?

▪ Kellgren and Lawrence System for classification of knee OA

• Grade 0 -- None
• Grade 1 -- Minor – usually no pain or discomfort
• Grade 2 -- Mild – pain after long day of running/walking, some

stiffness after immobile, sore when kneeling or bending

• Grade 3 -- Moderate – frequent pain, joint stiffness, some swelling
• Grade 4 -- Severe – great pain when walking or moving the knee

Kellgren and Lawrence, Ann Rheum Dis 1957

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What about an MRI to diagnose OA?

▪ MRI in the setting of OA will ALWAYS show a meniscus

tear

• Patients will get fixated on the meniscus tear
• Likely will want to undergo surgery
• Unclear how much benefit

▪ Indications for ordering an MRI

• Obvious and significant injury (especially in younger

patients)

• Associated severe effusion
• Locking of the knee (can’t straighten or bend)
• Non-operative treatments have failed

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Interventions

Kirkley et al, NEJM 2008; Juni et al, Cochrane Library 2015; McAlindon et al, JAMA 2017

▪ AKS (irrigation with saline and “clean-up”)

• Compared to Control group (PT/medical therapy)
• Significant improvement at 3 months with surgery (~ past

studies involving sham surgery), but thereafter, no difference in WOMAC scores

▪ Intraarticular cortisone injection vs. placebo injection

• Low quality evidence with inconclusive results re: pain relief,

improved function, and duration of steroid effect

• Q3 month RCT--IA TAC vs saline inj under US
• Signif more cartilage loss in TAC group; no signif diff in pain

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PT, Exercise and Strength Training

▪ Almost everyone will have some weakness and/or

functional limitations or imbalances that can be corrected

▪ The most effective PT interventions are exercise:

aerobic, aquatic, strengthening, and proprioception

• Evaluation of strength and gait
• Closed chain exercises
• Low to Non-impact aerobic exercise

▪ bike, elliptical, swimming, H2O rehab/exercises

• Joint capsule and muscle stretches
• Modalities as needed
• Daily home exercise and rehab self-management programs

Wang, AIM 2015; https://www.aaos.org/research/guidelines/oaksummaryofrecommendations.pdf

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Weight Management

• For every 1 lb weight loss, 4-6 lb  in force on the knee per step
• Pain reduction with even minimal weight loss
• Exercise alone without dietary changes not as effective
• Markers of cartilage turnover and breakdown are decreased

after bariatric surgery

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14th Annual UCSF Primary Care Sports Medicine Conference December 12- 14, 2019 Intercontinental San Francisco Join us in December

99

Join us on Saturday, January 11th

@ Cal Memorial Stadium

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UCSF Musculoskeletal Exam Tutor App

▪7 musculoskeletal cases ▪> 60 high quality exam videos

performed by UCSF experts

▪Apple app store

• Search UCSF

Musculoskeletal Exam App

▪$20 ▪iOs (Apple) devices only

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Check out our sports rehab guide for patients!

https://sportsrehab.ucsf.edu/

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Questions?

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