(My) 2017 Top Sports Medicine Conditions in Women UCSF - - PDF document

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(My) 2017 Top Sports Medicine Conditions in Women UCSF - - PDF document

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Disclosures None. (My) 2017 Top Sports Medicine Conditions in Women UCSF CME:Controversies in Womens Health Carlin Senter, MD Associate Professor Primary Care Sports Medicine UCSF Medicine and Orthopaedics Learning objectives Case #1 60

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SLIDE 1

(My) 2017 Top Sports Medicine Conditions in Women

UCSF CME:Controversies in Womens Health

Carlin Senter, MD Associate Professor Primary Care Sports Medicine UCSF Medicine and Orthopaedics

Disclosures

None.

Learning objectives

Upon completion of this session, participants should be able to:

  • 1. List 3 indications for knee arthroscopy
  • 2. List 5 treatment modalities for knee osteoarthritis
  • 3. Name 2 conditions in which the shoulder has limited active and

passive range of motion

  • 4. Define the female athlete triad
  • 5. Write an exercise prescription

Case #1

60 y/o woman presents with 3 months of medial knee pain. (+) swelling, and instability. No frank locking. Pain is worse with weight bearing. Better with rest, ice, and NSAIDs. She brings a knee MRI for your review. Exam: Neutral knee alignment when standing, tender medial joint line + medial femoral condyle + medial tibial plateau. Small effusion. ROM 0-120, limited by pain. Mild crepitus. (+) medial Mcmurray, medial knee pain with squat. No ligamentous laxity.

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SLIDE 2

Case #1: MRI results

  • Small effusion
  • Moderate chondrosis medial femoral condyle

and medial tibial plateau

  • Degenerative medial meniscus tear

Which of the following would you recommend?

  • A. Refer for arthroscopic debridement of meniscus

tear and lavage

  • B. Nonoperative knee OA program

C.Refer for total knee replacement

Case #1

60 y/o woman presents with 3 months of medial knee pain. (+) swelling, and instability. No frank locking. Pain is worse with weight bearing. Better with rest, ice, and NSAIDs. She brings a knee MRI for your review. Exam: Neutral knee alignment when standing, tender medial joint line + medial femoral condyle + medial tibial

  • plateau. Small effusion. ROM 0-120, limited by pain. Mild
  • crepitus. (+) medial McMurray, medial knee pain with
  • squat. No ligamentous laxity.

Clinical criteria for diagnosis of knee OA

Altman R et al. Arthritis Rheum. 1986 Aug;29(8):1039-49.

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SLIDE 3

Clinical criteria for diagnosis of knee OA

Altman R et al. Arthritis Rheum. 1986 Aug;29(8):1039-49.

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SLIDE 4

Arthritis epidemiology

  • Most common type = osteoarthritis
  • Affects 23% of all adults in the United States ( > 54 million people)
  • More common in women (24%) than men (18%)
  • Affects
  • ½ of US adults with heart disease
  • ½ of US adults with diabetes
  • 1/3 of US adults with obesity
  • Osteoarthritis was the 2nd most expensive health condition treated in US

hospitals in 2013

11/22/2017 9

https://www.cdc.gov/chronicdisease/resources/publications/aag/pdf/2016/aag-arthritis.pdf. Accessed November 18, 2017. McAlindon TE et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis

  • Cartilage. 2014 Mar;22(3):363-88.

Does arthroscopic partial meniscectomy (APM) help middle aged patients with osteoarthritis +/- degenerative meniscus tear?

  • Arthroscopy not indicated for knee OA as no more effective than non operative

care (Mosely JB et al, NEJM 2002; Kirkley A et al. NEJM 2008)

  • ¾ studies show no significant difference between APM + PT versus PT alone

(Gauffin H et al. Osteoarthritis Cartilage 2014; Herrlin SV et al. Knee Surg Sports Traumatol Arthrosc 2013; Katz JN et al. NEJM 2013; Yim JH et al. AJSM 2013.)

  • Limitation: difficult to interpret due to cross-over (30%) before assessment of

the primary outcome

  • Factors associated with crossover from PT to APM: shorter duration of

symptoms and higher initial pain score (Katz JN et al. JBJS 2016.)

Take-home points: knee OA, meniscus tears

  • Degenerative meniscus tear is part of the natural history of
  • steoarthritis
  • Treat as osteoarthritis initially with non surgical knee OA program
  • Imaging: Start with x-ray. Consider referral vs MRI if exam c/w

meniscus tear and not improving with PT

  • Could consider arthroscopic meniscus surgery if weight loss, PT,

medications, injections not helping or if patient prefers surgical treatment.

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SLIDE 5

McAlindon TE et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis

  • Cartilage. 2014 Mar;22(3):363-88.
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SLIDE 6

Indications for knee arthroscopy

  • Acute (not degenerative) meniscus tear, no arthritis
  • Locked or locking knee: Bucket handle meniscus tear or loose

body

  • Ligament tear
  • ACL – reconstruction
  • MCL – often treated conservatively but sometimes

reconstructed

  • PCL – depends on whether or not other structures injured
  • LCL – reconstruction (rare injury)

Which of the following would you recommend?

  • A. Refer for arthroscopic debridement of meniscus tear and

lavage

  • B. Nonoperative knee OA program
  • C. Refer for total knee replacement

60 y/o woman with 3 months knee pain due to medial compartment OA and degenerative tear of medical meniscus.

Case #2

50 y/o RHD woman with type 2 diabetes presents with 3 months of severe R shoulder pain. No injury. Waking up at night due to pain. Shoulder feels very stiff. She is having trouble reaching behind and raising arm above head. On exam she has no muscle atrophy and no point tenderness. There is decreased active and passive range of motion of the right

  • shoulder. Her rotator cuff strength is 5/5 though difficult to perform

due to limited range of motion and pain. R shoulder x-rays are normal.

How would you treat this patient?

A.Provide R shoulder sling to use for comfort. B.Provide shoulder steroid injection to reduce pain. C.Obtain shoulder MRI. D.Refer to surgeon for arthroscopy.

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SLIDE 7

Adhesive capsulitis

http://www.aurorahealthcare.org/he althgate/images/si55551230.jpg

Shoulder: diagnosis driven exam

Active ROM Decreased Normal Passive ROM Normal Decreased Xray Frozen shoulder Normal GH joint arthritis Abnormal Rotator cuff disease Labral tear Biceps tendinitis AC joint OA Adapted from: O'Kane and

  • Toresdahl. The evidenced-

based shoulder evaluation. Cur Sports Med Rep. 2014.

Abduction

Shoulder active range of motion Abduction Forward flexion

Internal rotation

Shoulder active range of motion External rotation Internal rotation

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SLIDE 8

Limited ER key finding

Adhesive capsulitis is a clinical diagnosis

  • No need for MRI
  • X-rays helpful to r/o glenohumeral joint arthritis

X-rays courtesy of Dr. Ben Ma

3 stages of adhesive capsulitis

Freezing Frozen Thawing

3-9 months ↑ pain ↓ ROM Pain at rest, sleep 4-12 months ↓ pain Stable, decreased ROM 12-42 months Gradual ↑ ROM Resolution Average time to resolution: 1-3 years

Treatment for adhesive capsulitis

  • Associated w/diabetes: A1c or fasting blood sugar
  • Pain control: NSAIDs or injected corticosteroids
  • Does not change disease course
  • Does help significantly with pain control
  • +/- physical therapy to help restore ROM
  • Capsular distention injections
  • Surgery (rarely)

Manske and Prohaska, Curr Rev Musculoskeletal Med, 2008. Griesser MJ et al. Adhesive capsulitis …a systematic review of intraarticular injections. J Bone Joint Surg Am. Sep 2011.

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SLIDE 9

How would you treat this patient?

  • A. Provide R shoulder sling to use for comfort.
  • B. Provide shoulder steroid injection to reduce pain.

C.Obtain shoulder MRI. D.Refer to surgeon for arthroscopy.

50 y/o RHD woman with 3 months severe R shoulder

  • pain. Limited active and passive range of motion.

Normal x-rays.

Case #3

  • 20 y/o collegiate cross country athlete
  • Presents to training room with right groin pain
  • Started a few weeks ago, getting worse gradually
  • Still able to run but pain gets worse the more she runs,

hard to lift her leg due to pain

Differential diagnosis groin pain in runner

  • Hip flexor strain
  • Femoral acetabular

impingement +/- hip labral tear

  • Sports hernia
  • Osteitis pubis
  • Femoral neck stress

fracture

  • GI/gyn problems

Falvey EC et al, BJSM. 2007. http://www.arthrohealth.com.au/wp- content/themes/ypo- theme/images/CAM-and-Pincer.jpg

5 questions for every runner with hip pain

  • 1. Training: increased mileage?
  • 2. Nutrition: Calories in versus calories out? History of

eating d/o? Dietary restrictions?

  • 3. History of stress fractures?
  • 4. Family history of osteoporosis?
  • 5. Menstrual history?
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SLIDE 10

Our patient

  • Increased mileage from 30 to 60 miles/week in last month

without increased caloric intake

  • No dietary restrictions or h/o eating d/o
  • (+) h/o tibial stress fracture in high school
  • No family history osteoporosis
  • Menses regular until college but none since freshman

year (18 months)

What’s your leading diagnosis?

  • A. Hip flexor strain
  • B. Femoral acetabular impingement
  • C. Sports hernia
  • D. Osteitis pubis
  • E. Femoral neck stress fracture
  • F. GI / gyn problem

High index of suspicion to prevent bad outcome

Risk factors for bone stress injury in female athletes

  • Low bone mineral density (Bennell, 1996; Kelsey, 2007;

Myburgh, 1990; Goolsby, 2008)

  • Delayed onset of menses and/or missing periods

(Goolsby,2008; Bennell, 1996; Myburgh, 1990)

  • Lower dietary calcium (Kelsey, 2007)
  • Lower dietary fat (Bennell, 1996)
  • History of stress fracture (Goolsby, 2008; Kelsey, 2007)
  • Restrictive eating (Goolsby, 2008; Bennell, 1996)
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SLIDE 11

Female athlete triad

Healthy energy status Healthy menstrual cycles Healthy bones Low energy availability with or without eating d/o Osteoporosis Amenorrhea Low bone density Suboptimal energy availability Irregular menses OPTIMAL HEALTH PATHOLOGY Nattiv A et al, ACSM Position Stand, 2007.

Female athlete triad =

the interrelationships between energy availability, menstrual function, and bone mineral density.

Nattiv A et al, ACSM Position Stand, 2007.

Triad Consensus Panel Screening Questions

  • Menstrual periods:
  • LMP?
  • # in past 12 months?
  • Age of menarche
  • Taking any female hormones, OCPs?
  • Weight
  • Do you worry about your weight?
  • Are you trying to or has anyone

recommended you gain or lose weight?

  • Are you on a special diet or do you avoid

certain foods?

  • Have you ever had an eating disorder?
  • Have you ever had a stress fracture?
  • Have you ever been told you have low bone

density? Mary Jane De Souza et al. Br J Sports Med 2014;48:289

Female athlete triad treatment

  • Best treatment = prevention
  • Screen for risk factors
  • Finding 1 risk factor should prompt eval for others
  • Increase energy availability
  • Increase dietary intake
  • Decrease exercise
  • Has been shown to restore menses
  • Has been shown to increase bone density
  • Estrogen: does not improve BMD as much as if menses are restored with increased energy

availability

  • Multidisciplinary approach

Nattiv A et al, ACSM Position Stand, 2007.

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SLIDE 12

Female athlete triad resource: http://www.femaleathletetriad.org/athletes/what-is-the-triad/

Case #4

  • 63 y/o woman presents for annual exam. Takes no medications.

Busy job, mostly on computer. Doesn’t have time for exercise but she walks 5 minutes to and from work 5 days/week.

  • BP 140/80, HR 80, Height: 5’3”, weight 170# (BMI 30)
  • Labs:
  • HgA1c 6.3%
  • Total cholesterol 192, TG 119, HDL 50, LDL 118
  • TSH normal

Definitions

  • Physical activity: any body movement that results in

energy expenditure (exercise, activities of daily living, active transportation)

  • Exercise: one kind of physical activity that is planned,

structured, repetitive with objective to improve or maintain physical fitness.

ACSM Position Stand on Prescribing Exercise, Med Sci Sports Ex, 2011.

Strong evidence that physical activity associated with lower risk of

  • Coronary artery disease
  • Stroke
  • High blood pressure
  • High cholesterol
  • Metabolic syndrome
  • Cognitive impairment
  • Type 2 diabetes
  • Colon cancer
  • Breast cancer
  • Falls
  • Weight gain
  • Depression

US Dept Health and Human Services. Physical Activity Guidelines Advisory Committee Report, 2008: https://health.gov/paguidelines/guidelines/chapter2.aspx. Accessed 11/18/2017.

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SLIDE 13

Percent of adults who achieve at least 150 minutes a week of moderate-intensity aerobic physical activity or 75 minutes a week of vigorous-intensity aerobic activity (or an equivalent combination) 2015

https://nccd.cdc.gov/dn pao_dtm/rdPage.aspx?rd Report=DNPAO_DTM. ExploreByTopic&islClass =PA&islTopic=PA1&go =GO. Accessed 11/18/17.

The exercise prescription: What’s the right dose of activity?

Credit: Piotr Redlinski for The New York Times

Physical activity recommendations: 4 types of activities

Cardiovascular Strength Balance Flexibility Physical activity recommendations: components of each activity

  • Frequency
  • Intensity
  • Time
  • Type
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SLIDE 14

Estimating exercise intensity

Low Moderate Vigorous HR <50% max 50-70% max >70% max Talk test Can talk and sing Can talk but not sing Can only say a few words before pause for breath Borg rating of perceived exertion 9 – very light (slow walk 11 – light 13 – somewhat hard 15 – hard (very heavy, tired) 17- very hard 19 – extremely hard 20 - max

ACSM Position Stand on Prescribing Exercise, Med Sci Sports Ex, 2011.

  • Rate of perceived

exertion x 10 = Heart rate

  • Good way to measure

intensity for person on medications that affect the heart rate (metoprolol, other beta blockers).

http://www.poliosurvivorsnetwork.org.uk/archive/lincolnshire/library/trojan/images/management_fig1.gif

Exercise prescription: Combine activity with components

  • Frequency
  • Intensity
  • Time
  • Type

Cardiovascular Strength Balance Flexibility CV fitness recommendations

Frequency Intensity Time Type 5x/week Moderate 30 minutes Major muscle groups

OR

Frequency Intensity Time Type 3x/week Vigorous 20 minutes Major muscle groups

ACSM Position Stand on Prescribing Exercise, Med Sci Sports Ex, 2011. https://go4life.nia.nih.gov/ Accessed 11/18/17.

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SLIDE 15

Strength recommendations

Frequency Intensity Time Type 2-3d/week Novice: 40-50% Experienced: 80% Unknown All major muscle groups

https://go4life.nia.nih.gov/ Accessed 11/18/17. ACSM Position Stand on Prescribing Exercise, Med Sci Sports Ex, 2011.

Balance recommendations

Frequency Intensity Time Type 2-3d/week Unknown 20 minutes Tai Chi, tennis, yoga, surfing

ACSM Position Stand on Prescribing Exercise, Med Sci Sports Ex, 2011. https://go4life.nia.nih.gov/ Accessed 11/18/17.

Flexibility recommendations

ACSM Position Stand on Prescribing Exercise, Med Sci Sports Ex, 2011.

Frequency Intensity Time Type 2-3d/week Stretch to feeling of tightness Hold 10-30 seconds All major muscle- tendon units

https://go4life.nia.nih.gov/ Accessed 11/18/17. Medicine & Science in Sports and Exercise, 2009.

Age-adjusted all-cause death rate per 10,000 person-years

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SLIDE 16

Estimated daily time spent in different contexts of energy expenditure among adults, based on the National Health and Nutrition Examination Survey.

Light time=24–MVPA–Sleep–Sedentary time. MVPA indicates moderate to vigorous physical activity.

  • Circulation. 2016;134:e262-e279
  • Insufficient physical activity predicts premature cardiovascular disease and mortality
  • Prospective evidence suggests that sedentary behavior could be a risk factor for cardiovascular disease,

diabetes and all-cause mortality

  • Estimated that adults spend 6 – 8 hours /day in sedentary behavior
  • Those who met physical activity guidelines had similar # sedentary hours to those who did not
  • Association between TV viewing time and sedentary behavior
  • Prevalence is greater in older adults
  • Data conflicts regarding differences in sedentary behavior by sex or race/ethnicity

Think of sedentary behavior and physical activity as 2 factors as separate and unique determinants of health

  • Circulation. 2016;134:e262-e279

Interventions to reduce sedentary behavior

  • Activity-permissive workstation (stand, walk or pedal while

working): decreased sedentary behavior by 77 minutes in 8 hour day (Neuhaus M et al. Reducing occupational sedentary time: a systematic review and meta-analysis of evidence on activity-permissive workstations. Obes Rev. 2014;15:822–838.)

  • Smartphone apps to monitor and interrupt sedentary behavior

in real time significantly decreased sedentary time (Bond DS et

  • al. B-MOBILE: a smartphone-based intervention to reduce

sedentary time in overweight/obese individuals: a within- subjects experimental trial. PLoS One. 2014;9:e100821.)

Exercise prescription resources

http://bleacherreport.com/articles/1189176-bay-to-breakers-2012-changes-the-race-must-make

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SLIDE 17

Estimated daily time spent in different contexts of energy expenditure among adults, based on the National Health and Nutrition Examination Survey.

Light time=24–MVPA–Sleep–Sedentary time. MVPA indicates moderate to vigorous physical activity.

  • Circulation. 2016;134:e262-e279
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SLIDE 18

https://www.cdc.gov/physicalactivity/basics/index.htm. Accessed 11/18/2017. https://go4life.nia.nih.gov/ Accessed 11/18/2017.

(My) 2017 Top Sports Medicine Conditions in Women

1.Arthritis 2.Frozen shoulder 3.Female athlete triad 4.Physical inactivity

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SLIDE 19

Take-home points

  • 1. List 3 indications for knee arthroscopy
  • 2. List 5 treatment modalities for knee osteoarthritis
  • 3. Name 2 conditions in which the shoulder has limited

active and passive range of motion

  • 4. Define the female athlete triad
  • 5. Write an exercise prescription
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SLIDE 20

Female athlete triad: Cumulative risk assessment

Mary Jane De Souza et al. Br J Sports Med 2014;48:289

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SLIDE 21

Female Athlete Triad: Clearance and Return-to-Play (RTP) Guidelines by Medical Risk Stratification.

*Cumulative Risk Score determined by summing the score of each risk factor (low, moderate, high risk) from the Cumulative Risk Assessment. Mary Jane De Souza et al. Br J Sports Med 2014;48:289