Return to Play: Case Challenges Drew A. Lansdown, MD Assistant - - PowerPoint PPT Presentation

12/14/2018 1

Return to Play: Case Challenges

Drew A. Lansdown, MD Assistant Professor in Residence UCSF Department of Orthopedic Surgery Sports Medicine & Shoulder Surgery

Financial Disclosures

• No relevant financial disclosures related to this talk

Outline

Goals

• Clarify factors that

contribute to timing of return to play

• Case-based presentations

with active participation Review the framework for return to play decisions Discuss five cases and highlight important factors that contribute to timing of return to play

• Knee
• Shoulder
• Hip

1. 2.

The Team Physician and the Return-To-Play Decision: A Consensus Statement (2012 Update )

• These consensus statements are developed by the collaborative effort of 6

major professional associations:

PANEL, EXPERT. "The team physician and the return-to-play decision: a consensus statement—2012 update." (2012).

12/14/2018 2

The Team Physician and the Return-To-Play Decision: A Consensus Statement (2012 Update )

• Definition:
• Return-To-Play is the decision-making process of returning an

injured or ill athlete to practice or competition.

• Goal:
• The goal is to return an injured or ill athlete to practice or

competition without putting the individual at undue risk for injury or illness.

Slide courtesy of Cindy Chang, MD

The Team Physician and the Return-To-Play Decision: A Consensus Statement (2012 Update )

• Key Points:
• It is essential that the team physician

ultimately be responsible for the RTP decision.

• Individual decisions regarding RTP may be

complex and will depend on the specific facts and circumstances presented to the team physician.

Slide courtesy of Cindy Chang, MD

The Team Physician and the Return-To-Play Decision: A Consensus Statement (2012 Update )

• The status of anatomical and

functional healing

• The status of recovery from acute

illness and associated sequelae

• The status of chronic injury or illness
• That the athlete pose no undue risk

to the safety of other participants

• Restoration of sport-specific skills
• Psychosocial readiness
• Ability to perform safely with

equipment modification, bracing, and orthoses

• Compliance with applicable federal,

state, local, school, and governing body regulations

Slide courtesy of Cindy Chang, MD

Return to Play Decision Making

Final Return to Play Decision Medical Factors

• Patient demographics
• Symptoms
• Medical history
• Physical exam
• Lab/Imaging Tests
• Functional Tests
• Psychological State
• Potential Seriousness

Sport Risk Modifiers

• Type of sport
• Position
• Limb dominance
• Competitive level
• Ability to protect

(padding) Decision Modifiers

• Timing & season
• Pressure from

athlete

• External pressure
• Masking the

injury

• Conflict of

interest

• Fear of litigation

12/14/2018 3

Return to Play Cases Case #1: Knee Sprain

• 20 year old woman presents with new-onset right knee pain after

collision with another player while playing soccer:

• Seen 3 days after injury
• Pain is medial at the right knee
• No knee effusion
• Pain with valgus stress and
• pening of 3-4 mm
• Negative Lachman
• Negative pivot

Image: fittoplay.org

ARS Question

Most likely diagnosis for this patient?

• A. ACL tear
• B. MCL sprain
• C. Lateral meniscus injury
• D. Patellar cartilage injury

ACL tear MCL sprain Lateral meniscus injury Patellar cartilage injury

3% 0% 11% 86%

Medial Collateral Ligament

Function

• Protect against valgus stress at the knee
• Comprised of deep and superficial components

Exam

• Best isolated with knee flexed to 30 degrees
• Check at 0 degrees with laxity in extension

suggesting associated ligament injury

• Evaluating for pain and opening

Grading

• Grade 1: Stretch
• <5 mm opening to valgus stress at 30 degrees
• Grade 2: Partial Tear
• 5-9 mm opening to valgus stress at 30 degrees
• Still with an end point to valgus stress
• Grade 3: Complete Tear
• >1 cm opening to valgus stress at 30 degrees

12/14/2018 4

MCL Injuries

• Mid-substance healing is

quicker than injury at insertion

• MCL more common due to

contact injury

• More common in last 15

minutes of a half

• Likely inability to protect due

to fatigue

Illustration from Laprade, et al. JBJS, 2007.

When Will I Be Able To Play?

• A. Tomorrow
• B. 2 weeks
• C. 3 months
• D. 6 months
• E. 1 year

EXAM

• Pain is medial at the right knee
• No knee effusion
• Pain with valgus stress and
• pening of 3-4 mm
• Negative Lachman
• Negative pivot

DIAGNOSIS Grade 1 MCL sprain

T

• m
• r

r

• w

2 w e e k s 3 m

• n

t h s 6 m

• n

t h s 1 y e a r

5% 73% 0% 0% 22%

• Longitudinal cohort of isolated

MCL sprains at US Military Academy from 2005-2009

• 128 cadets with MCL injuries:

rate of 7.3 per 1,000 person- years

• Median return to play timing:
• Grade 1: 13.5 days
• Higher grade: 29 days

Role of Bracing

• Hinged knee brace with side

supports

• Brace may allow for early motion
• Recommend bracing a Grade 2
• r 3 injury
• Not much benefit for Grade 1

injury

12/14/2018 5

When Should I Get More Imaging?

• Knee effusion
• Restricted range of motion
• Opening to valgus stress in

full extension

• Suspect another ligament is

injured

• Persistent symptoms that are

not responding to conservative treatment

MCL

Case #2: Another Knee Injury

• 21 yo male, collegiate wrestler,

presents with right knee injury

• Wrestling a heavyweight teammate

and right knee buckled

• Felt a pop, immediate pain, and

swelling soon after

• Exam:
• Range of motion: 10-90 degrees
• Large effusion
• No specific tenderness
• 2B Lachman
• Stable to varus and valgus stress at

0 and 30 degrees

ARS Question: What Is The Most Likely Diagnosis?

Most likely diagnosis is:

• A. ACL tear
• B. MCL sprain
• C. Lateral meniscus injury
• D. Patellar cartilage injury

History:

• Pop and immediate swelling

Exam:

• Range of motion: 10-90 degrees
• Large effusion
• 2B Lachman
• Stable to varus and valgus stress at 0

and 30 degrees

A C L t e a r M C L s p r a i n L a t e r a l m e n i s c u s i n j u r y P a t e l l a r c a r t i l a g e i n j u r y

93% 2% 2% 2%

What Should We Do Next?

A. Brace and protected weight bearing, follow up in 6 weeks B. Progressive mobilization and return to wrestling in 1-2 days C. Ice, NSAIDs, and re-evaluate next week D. MRI of the knee

History:

• Felt a pop
• Immediate swelling

Exam:

• Range of motion: 10-90

degrees

• Large effusion
• No specific tenderness
• 2B Lachman
• Stable to varus and valgus

stress at 0 and 30 degrees Diagnosis: Acute ACL injury

B r a c e a n d p r

• t

e c t e d w e i . . . P r

• g

r e s s i v e m

• b

i l i z a t i

• n

. . . I c e , N S A I D s , a n d r e

• e

v a l u . . . M R I

• f

t h e k n e e

17% 83% 0% 0%

12/14/2018 6

• 121 active young adults with acute ACL injuries
• Randomized to:
• Initial rehabilitation and early surgical ACL

reconstruction

• Rehabilitation and possible delayed ACL

reconstruction if needed

• 60 patients treated with early reconstruction
• 59 treated with rehabilitation
• 36 successfully managed with rehab alone
• 23 underwent delayed ACL reconstruction
• Avoided surgery in 61%

Non-Operative Treatment of ACL Tears

• May require crutches/brace initially for support
• Range of motion, quad strengthening
• Core/hamstring strengthening exercises
• Balance/proprioception
• Functional screening prior to return to sport
• Anticipate at least 10-12 weeks before return to activity
• 40% chance of late reconstruction

Risks of Non-Operative Treatment

• Possibility of late ACL

reconstruction

• Meniscal/cartilage injuries
• Other ligamentous injuries

to the knee

• Meta-analysis including 7,556 participants

81%

Return to Sport

65%

Return to Pre- Injury Level

55%

Return to Competitive Level

12/14/2018 7

Progression of Activity after ACL Reconstruction

• Brace for 6 weeks
• Return to sports based on functional testing
• Running at ~4 months
• Cutting/pivoting sports as early as 6

months after surgery

• For most, 9-12 months after surgery
• Functional testing:
• Single leg squat control before starting to

run

• Hop tests when closer to returning to

sport

Risk of Re-Injury

• Re-injury with return to play
• Rate varies based on timing of return
• 51% decrease per month of extended rehabilitation
• Desire to return to play/not miss a season
• Functional evaluation prior to return
• Role of bracing in return to play

When Can I Wrestle Again?

• Rising senior
• One year of eligibility left for collegiate

wrestling

• 7 ½ months until qualifying tournament

for next year

• Treatment plan:
• Restore range of motion quickly (2-3

weeks)

• ACL reconstruction with BTB

autograft

• Close communication with training

staff

Case #3: Meniscus Tears

• 16 year old girl with 4 months of right

knee pain:

• Hyperextended knee going after

contested ball in soccer game

• Felt pain, but able to keep playing
• No pop
• Knee swelling that night
• Continued to play
• Pain and swelling after playing and after

even walking

• Exam: + McMurray’s laterally, tender at

lateral joint line

• MRI: radial tear of lateral meniscus

12/14/2018 8

When Will I Be Ready to Play Soccer?

• A. 1-2 weeks
• B. 2-3 months
• C. 6-9 months

EXAM:

• + McMurray’s laterally
• Tender at lateral joint line

MRI: Radial tear at lateral meniscus

1

• 2

w e e k s 2

• 3

m

• n

t h s 6

• 9

m

• n

t h s

3% 17% 80%

Meniscus Function & Treatment of Tears

• Fibrocartilage structures comprised of anterior horn, body, and

posterior horn

• Circumferential collagen bundles function through hoop stress
• Distribute load across a larger surface area to protect breakdown of

tibiofemoral cartilage

• Blood supply from periphery

Figure: Bhatia, et al. AJSM, 2014.

• 81 patients evaluated after meniscus

repair (N=42) or meniscectomy (N=39)

• Progression of OA noted in 60% after

meniscectomy compared to 20% after meniscus repair

• Meniscus repair showed higher return to

pre-injury activity levels:

• 96% for repair
• 50% for meniscectomy
• Partial meniscectomy has

lower re-operation rate

• 1.2-3.9% for partial

meniscectomy

• 16-20% for meniscus repair

Not All Meniscus Tears Are The Same

• Video of repair vs debridement
• 16 years old
• Radial tear
• Acute injury
• 65 years old
• Flap tear
• Chronic injury

12/14/2018 9

Determining Treatment

Meniscus Repair Partial Meniscectomy Advantages Better functional outcomes Lower re-operation rate Lower risk of osteoarthritis Quicker recovery Disadvantages Potential for re-tear/repair failure Loss of chondroprotection from portion of meniscus

Factors to Consider:

• Tissue quality
• Patient age
• Tear pattern
• Tear location
• Willingness to rehab

Repairing vs Debriding Meniscus

Meniscus Debridement Meniscus Repair Weightbearing As tolerated after surgery Up to 6 weeks restricted/crutches Brace None needed 6 weeks with hinged knee brace Return to Running 4-6 weeks 4-5 months Return to Sport 4-6 weeks 6-9 months

Case #4: Shoulder Instability

• 19 yo M, defensive lineman,

with right shoulder injury during first game of the season (August):

• Deformity on the field
• Reduced on the field by team

physician

• No prior history of shoulder

instability/dislocations

Image: Ted S. Warren, AP Insidethepylon.com

The Next Week… Can I Play?

One week later Full range of motion Full strength No pain ARS Question

• A. Yes
• B. No

Y e s N

• 61%

39%

12/14/2018 10

Age is Key in Risk of Re-Dislocation

Re-Dislocation Rate Patient Age McLaughlin (Am J Surg, 1950) Rowe (OCNA, 1980) Cofield (AJSM, 1984) Robinson (JBJS 2006)

<20 yo 90% 94% 66% 49% 20-40 yo 60% 74% 40% 21% >40 yo 10%

Simonet and Cofield: 82% in young athletes vs. 30% in non-athletes

• Intercollegiate athletes with in-season shoulder dislocation
• 73% of athletes returned to sport at median of 5 days
• 27% completed the season without recurrent instability
• 64% had recurrent dislocation or subluxation
• 39 intercollegiate contact athletes
• 10 chose non-operative treatment
• 4 played next season without recurrence (40%)
• 29 chose surgical treatment
• 26 played the next season without recurrence

(90%)

• 9/20 had stabilization after first dislocation
• 20/29 continued playing and had recurrent

instability

• No difference in outcomes between these groups
• Relative to first-time dislocators, patients with

recurrent dislocations have:

• More anterior glenoid erosion
• More labral/periosteal sleeve avulsion
• Higher failure rates after stabilization
• Lower patient-reported satisfaction
• More associated intra-articular injuries

12/14/2018 11

Return to Play Algorithm for Anterior Shoulder Instability

First-Time Anterior Shoulder Dislocation? Elite Athlete? In Season? Recurrent Instability? Consider non-operative rehabilitation Trial return to play with discussion of off-season stabilization Surgical Stabilization

Post-Operative Rehabilitation

Weeks 0-6: Healing of Labrum

• Sling use
• Passive range of motion in physical therapy

Weeks 6-12: Mobilization

• Out of sling
• Active range of motion
• Scapular stabilization exercises

Weeks 12-18: Strengthening • Gentle strengthening exercises Weeks 18+: Sports

• Progressive strengthening
• Return to competitive activities

Case #5: A Pop While Kicking

• 30 yo M construction worker and soccer player who was playing

soccer and felt a pop in his left upper thigh when kicking.

• Exam:

‒Bruising through posterior thigh ‒Tender to palpation at proximal thigh near ischial tuberosity ‒Full range of motion at the hip ‒Weakness with resisted knee flexion

What Is The Next Best Step?

• A. MRI of the proximal thigh
• B. Anti-inflammatories/ice and

encourage return to activity

• C. 6 weeks of physical therapy

then re-evaluation

EXAM

• Bruising through posterior thigh
• Tender to palpation at proximal

thigh near ischial tuberosity

• Full range of motion at the hip
• Weakness with resisted knee

flexion

MRI of the proximal thigh Anti-inflammatories/ice ... 6 weeks of physical ther...

81% 15% 4%

12/14/2018 12

Hamstring Injuries

• Hamstrings comprised of:
• Biceps femoris
• Semimembranosus
• Semitendinosus
• Function: hip extension and knee

flexion

• Injury often occurs during:
• Sprinting/running
• Kicking
• Dancing
• Water skiing
• Key: combined hip flexion and

knee extension

Image: aaos.org

Risk Factors for Hamstring Injuries

• History of primary hamstring strain1
• Age1
• Increased body weight1
• Strength imbalance between quadriceps and hamstrings2
• Limited quadriceps flexibility2
• Poor core strength and limited pelvic coordination2

1. Sherry, M. Sports Health, 2012. 2. Heiderscheit, et al. JOSPT, 2010.

Differentiating Hamstring Strain From Proximal Hamstring Avulsion

• Proximal tendon injury:
• Pain with sitting
• Pain at ischial tuberosity
• Pop at time of injury
• Palpable defect near tendon
• rigin
• Extensive bruising
• Hamstring strain:
• Tenderness through muscle

belly/musculotendinous junction

Image: orthobullets.com

Hamstring Exam & Grading of Injury

• Exam:
• Check strength of knee flexion with knee at 15 degrees and 90 degrees of flexion
• Can internally/externally rotate the leg to isolate medial/lateral hamstrings
• Straight leg raise
• Popliteal angle
• Location of maximal tenderness

‒ More proximal location = longer recovery time frame

• Clinical grading:
• Grade 1 – mild
• Grade 2 – moderate
• Grade 3 – severe
• Grading can help determine optimal treatment and likely return to play timeline

12/14/2018 13

• Evaluation of 23 European soccer clubs over 5 year period
• 70% of injuries show no fiber disruption but still have significant time missed from sport

Grading

• Grade 0: No visible pathology
• Grade 1: Edema but no architectural disruption
• Grade 2: Architectural disruption and partial Tear
• Grade 3: Complete muscle tear or tendon rupture

Muscle Strain Progression

Phase 1

• Limit excessive stretching of hamstring
• May need crutches initially
• Look for pain-free walking/light jogging and 50-

70% isometric strength for progression Phase 2

• Progressive stretching
• Agility drills
• Core strengthening/stabilization exercises
• Avoid eccentric contractions or end-range

lengthening Phase 3

• Agility and sport-specific activities
• Return to sport when full strength, full range of

motion, and normal functional strength

Surgical Treatment

• Indications:
• >2 cm of tendon retraction
• Involvement of 2 or more

tendons

• Prefer to treat soon after injury

rather than in delayed fashion

• Surgical approach:
• Suture anchors into the ischial

tuberosity

• Repair tendons back to

anatomic origin

Suture Anchors

Rehabilitation After Repair

Phase 1 Weeks 0-6

• Hinged knee brace with waist support
• Limits knee extension and hip flexion
• Crutches, non-weight bearing

Phase 2 Weeks 6-8

• Progressive motion
• Re-gain knee extension
• Transition out of brace and to normal walking

Phase 3 Weeks 8-12

• Progressive strengthening

Phase 4 Months 3-6

• Advanced strength and coordination exercises
• Light running at 5-6 months
• Return to sport when strength is >75% of normal

side

12/14/2018 14

Conclusions

• Return to play decisions are multifactorial and complex
• Early and accurate diagnosis can allow for appropriate

treatment and prognostication of timing for return

Medical Factors

• Patient demographics
• Symptoms
• Medical history
• Physical exam
• Lab/Imaging Tests
• Functional Tests
• Psychological State
• Potential Seriousness

Sport Risk Modifiers

• Type of sport
• Position
• Limb dominance
• Competitive level
• Ability to protect

(padding) Decision Modifiers

• Timing & season
• Pressure from

athlete

• External pressure
• Masking the injury
• Conflict of interest
• Fear of litigation

Thank you! Drew Lansdown, MD drew.lansdown@ucsf.edu