“Sports Medicine for Primary Care Physician’s”

“Sports Medicine for Primary Care Physician’s” Dr. Donald W. Kucharzyk The Orthopaedic, Pediatric & Spine Institute Crown Point, Indiana

“Sports Medicine for Primary Care Physician’s” • Pediatric Athletic Sports Related Injuries • Female Athletic Sports Injuries • Preventing Sports Injuries in Female Athletes • COX-2 Specific Inhibitors: Emerging Role in Sports Medicine

“Sports Medicine for Primary Care Physician’s” “Musculoskeletal Overuse Syndromes”

“Sports Medicine for Primary Care Physician’s” • Increased Musculoskeletal stress is common in our young athletes recently • Reflects the escalating intensity of training and competition at younger ages • Athletes go from one sport to the next with prolonged seasons and little rest • Excessive use produces unresolved stresses on normal tissues that has yet to adapt and leads to failure and overuse

“Sports Medicine for Primary Care Physician’s” • Overuse injuries occur at two particular times during training • First occurs when “underused” athletes who are partially conditioned are placed in demand situations: pre-season football and cross country • Second occurs in the extremely fit athlete who are participating in multiple sports resulting in depletion of tissue reserves

“Sports Medicine for Primary Care Physician’s” • History is the best primary aid to the diagnosis of overuse injuries • Mechanical Pain that is produced by activity and relieved by rest is the hallmark anatomic factor • Environmental factors such as playing surfaces and equipment play a role • The most significant factor though is the training program’s: sudden increases or changes

“Sports Medicine for Primary Care Physician’s” • Overuse treatment protocol involves five phases: • Identify risk factors • Modify offending factors • Institute pain control • Undertake progressive rehabilitation • Continue maintenance to prevent re-injury

“Sports Medicine for Primary Care Physician’s” “Stress Fractures” • Stanitski proposed the etiology to be the result of highly concentrated eccentric and concentric muscle forces acting across specific bones and compounded by specific sports specific demands predispose the bone to failure • Loss of normal time frame for bone repair submaximal trauma produces the fracture

“Sports Medicine for Primary Care Physician’s” • Muscle fatigue also plays a role in stress fractures • With fatigue of the muscle envelope, greater stress is absorbed by the underlying bone and predispose to stress fractures • Increased muscle force--change in remodeling rate--resorption and rarefaction--microfractures--stress fx

“Sports Medicine for Primary Care Physician’s” • Standard radiographs are not helpful because early phase stress fractures are radiographically silent • Bone Scan’s are extremely helpful but may not be positive till 12-15 days post injury • Locations involve primarily the tibia but also has been seen in the upper extremity such as the humerus and radius; and proximal femoral neck

“Sports Medicine for Primary Care Physician’s” • Treatment regime involves immobilization via a pneumatic leg brace: this helps distribute the stress across the soft tissue envelope that will diminish stress across the fracture and allow healing to progress • Post healing rehabilitation is critical as well as evaluating the mechanics of the injury and training/conditioning and gait too.

“Sports Medicine for Primary Care Physician’s” “Stress Injuries of the Growth Plate” • Must be aware that chronic stress injuries can cause physeal damage • Runner’s show this manifestation in the distal femur and proximal tibia--attention to history, clinical exam, and xray evaluation important..confused with neoplasm • Area’s Affected Include: Proximal Humerus commonly seen in Pitcher’s

“Sports Medicine for Primary Care Physician’s” • Gymnasts have the most common physeal stress fracture seen affecting the distal radius--will retard growth and produce an overgrowth of the ulna and wrist pain • Treatment is rest, immobilization, avoidance, rehabilitation, and conditioning • Treatment course involves at least 3 months of avoidance and then rehabilitation

“Sports Medicine for Primary Care Physician’s” “Little League Shoulder” • Microtrauma and overuse to the upper extremity localized to the proximal humerus • Mechanics of pitching produces stress across the physis during the cocking phase, acceleration phase, and the follow-through-greatest stress on physis at this time • Radiographs reveal widening of the proximal humeral physis

“Sports Medicine for Primary Care Physician’s” • Treatment is rest from throwing for the remainder of the season plus a vigorous preseason conditioning program the following year • Recommendation to the family involves the evaluation of the athletes throwing mechanics, in immature pitcher’s development of skill and control, then with maturity develop speed and velocity

“Sports Medicine for Primary Care Physician’s” “Little League Elbow” • Medial elbow pain in tennis player’s, javelin thrower’s, and football quarterback’s • Complex grouping of injuries involving medial epicondylar fractures, medial apophysitis, and ligamentous injuries • Pain is the most common complaint • Duration of pain aides in the diagnosis

“Sports Medicine for Primary Care Physician’s” • Short duration: must consider avulsion fx • Longer duration: consider ligamentous injury or medial apophysitis • Radiographs lead to the diagnosis in fractures, but normal variants must be understood especially medially • MRI gaining importance in use in these injuries as it gives great details of all the structures

“Sports Medicine for Primary Care Physician’s” • Treatment is diagnosis specific: *Medial Apophysitis-medial pain,diminished throwing effectiveness, and decreased distance: rest (4-6 weeks), NSAID, ice, gradual return to conditioning and resume throwing at about 8 weeks *Medial Epicondylar Fractures-nondisplaced treat with cast and rehab; displaced 3mm or more treat with ORIF

“Sports Medicine for Primary Care Physician’s” *Medial Ligament Rupture-sudden onset of severe pain with instability; treatment is via direct surgical repair and if tenuous then supplement with a palmaris longus graft

“Sports Medicine for Primary Care Physician’s” “Panner’s Disease” • Osteochondrosis of the capitellum (necrosis or fragmentation followed by recalcification) • Seen in children aged 7 to 12 years of age • Dull,ache that is aggravated by activity especially throwing • Pain always LATERAL • Radiographs reveal fragmentation and irregularities of the capitellum

“Sports Medicine for Primary Care Physician’s” • Treatment involves initially rest, avoidance of throwing, and splinting until pain and tenderness subsides • Rehabilitation and reconditioning of the upper extremity post recover important • Late deformity and collapse of the articular surface of the capitellun uncommon

“Sports Medicine for Primary Care Physician’s” “Iliac Apophysitis” • Iliac crest tenderness on palpation and muscular contraction seen primarily in adolescent long distant runner’s • No local trauma but history of extensive intensive training programs • Radiographs are normal • Treatment is rest (4-6weeks), ice, NSAID, progressive return to sports

“Sports Medicine for Primary Care Physician’s” “Osgood-Schlatter Disease” • Classic presentation is seen in preteen or early teenage children with activity related discomfort, swelling, and tibial tubercle tenderness • Bilateral occurrence in 20 to 30% • Etiology is submaximal repetitive tensile stresses acting on an immature patellar tendon-tibial tubercle junction

“Sports Medicine for Primary Care Physician’s” • Muscle imbalance is commonly seen with weakness in the quadriceps sometimes significant • Treatment is avoidance of activity, rehabilitation of the weak quadriceps, hamstrings and flexibility training, and progressive return to sports • Family must understand that it can take from 12 to 18 months for all symptoms to subside

“Sports Medicine for Primary Care Physician’s” “Sinding-Larsen-Johansson Disease” • Anterior knee pain at inferior pole of the patella • Seen commonly in 10 to 12 year olds • Tenderness seen at the inferior end of the patella at the tendon-bone junction • Must evaluate for sleeve fracture or patellar stress fractures if history of sudden onset

“Sports Medicine for Primary Care Physician’s” • Treatment involves rest, ice, NSAID, and occassionally a knee sleeve for protection • Rehabilitation program to promote flexibility, quadriceps and hamstring conditioning, and return to normal activities to tolerance

“Sports Medicine for Primary Care Physician’s” “Slipped Capital Femoral Epiphysis” • Most common hip disorder seen in adolescent • Slippage of the proximal femoral epiphysis • Seen in two body types: tall, slender, rapidly growing or the short, obese child • Bilateral in 50% • Common cause of anterior thigh or knee pain, athlete’s with knee pain should have the hip evaluated too

“Sports Medicine for Primary Care Physician’s” • Gait abnormality is the common initial presenting complaint with a limp seen • External rotational deformity of the hip seen (obligatory external rotation) • Pain can be seen: under 3 weeks (acute); over 3 weeks (chronic) • Treatment is immediate percutaneous hip pinning

“Sports Medicine for Primary Care Physician’s” “Patello-Femoral Malalignment” • Common source of sports disability especially in jumpers and those sports requiring rapid changes in direction • May be related to congenital, acquired such as in Down’s or Ehlers-Danlos syndrome, or acquired due to trauma • Can be seen in association with flexible flat footedness due to valgus thrust on the patella

“Sports Medicine for Primary Care Physician’s” • Common symptoms include vague, localized anterior knee discomfort • Seen following prolonged sitting, stair accent and descent, and with increase levels of activity • Clinically evaluate for mechanical alignment of the lower extremity, movement of the patella on flexion/extension, quadriceps function and size, hamstring function and overall flexibility

“Sports Medicine for Primary Care Physician’s” • Gait analysis for femoral anteversion or tibial torsion should be studied as well as the evaluation for flexible flat footedness • Radiographic evaluation involves plain x-rays with Merchant view to see patellar alignment and position • Treatment is symptomatic via rest, NSAID, physical therapy and sometimes bracing

“Sports Medicine for Primary Care Physician’s” • Rehabilitation is the key to preventing the reoccurrence of the condition • Failure to respond with prolonged symptoms and persistent subluxation with pain may benefit from arthroscopic lateral retinacular release • Long term sequlae may predispose the patient to the development of chondromalacia patella

“Sports Medicine for Primary Care Physician’s” “Osteochondritis Dissecans” • Lesion of bone and articular cartilage of uncertain etiology that results in delamination of subchondral bone with articular cartilage mantle involvement • Peak appearance is seen in early adolescence with male predominance 3:1 • Seen in the knee but can also be seen in the ankle involving the talus and the patella

“Sports Medicine for Primary Care Physician’s” • Clinically presents with vague knee pain that is aggravated with sports, intermittent swelling seen, and at times a feeling of the knee locking • Physical exam is nonspecific • Radiographic evaluation includes x-ray's and if indicated an MRI • Most importantly, must differentiate acute lesion’s from silent “chronic” lesions

“Sports Medicine for Primary Care Physician’s” • Treatment geared to eliminate the pathologic process and clinical condition via repair or resection of the lesion • Chronic lesion’s loose bodies require removal arthroscopically and debridement of the bed • Acute lesion’s require drilling of the bed and fixation arthroscopically to allow the lesion to heal

“Sports Medicine for Primary Care Physician’s” • Patellar osteochondritis is treated similar to that of femoral osteochondritis with arthroscopic evaluation and debridement and curettage of the lesion • Lesion commonly seen in the lower third of the patella and is due to increased patello-femoral contact force during flexion in the presence of weak quadriceps and minor trauma

“Sports Medicine for Primary Care Physician’s” “Ligamentous Injuries” • Common in Athletes • Loaded in tension to provide both static and dynamic support to the knee • Knee has motion that occurs in three planes and requires this static and dynamic support • Kinematics of the Knee shows that any one plane motion is always coupled with a second plane motion

“Sports Medicine for Primary Care Physician’s” • Must Understand the Healing Process of the different ligaments • Collateral Ligaments have a rich blood supply from the surrounding tissue and heals well with conservative care • Cruciate Ligaments have a sparse blood supply from surrounding tissue and bone attachment and do not heal well with conservative care

“Sports Medicine for Primary Care Physician’s” • Healing process begins with fibrin clot formation and then a local inflammatory response • First week post: local vascular and fibroblast proliferation • Second week post: fibroblasts become organized into a parallel network • Third week post: tensile strength increases

“Sports Medicine for Primary Care Physician’s” • Eighth week post: normal appearing ligament is now present • Early range of motion critical to increasing the strength and energy-absorbing capacity of the ligament • Immobilization not favorable to healing and recover of the ligament

“Sports Medicine for Primary Care Physician’s” “Medial Collateral Ligament” • Primary restraint to valgus stress • Commonly injured by a direct blow to the lateral side of the knee with the foot planted • Clinical signs reveal tenderness at the medial epicondyle with localized swelling • Pain on valgus stressing or laxity seen define the grade of injury

“Sports Medicine for Primary Care Physician’s” “Lateral Collateral Ligament” • Primary restraint to varus stress • Commonly injured with direct blow to the medial side of the knee with the foot planted • Clinical signs reveal tenderness over the lateral epicondyle with localized swelling • Pain with varus stressing or laxity reveal the grade of injury

“Sports Medicine for Primary Care Physician’s” “Treatment of Collateral Injuries” • Grade I do not require bracing, Grade II and III require the use of a hinged ROM brace with motion limited at 10 to 75 deg. initially for the first three weeks • Early therapy important and include patellar mobilization, isometric quadriceps and hamstring exercises with modalities of whirlpool, E-Stim., and biofeedback

“Sports Medicine for Primary Care Physician’s” • Bracing discontinued for Grade II and III at four weeks and achieving full ROM is now the goal • Once FULL ROM achieved then begin flexibility and strengthening program • Program includes: leg presses, mini-squats, resisted knee flexion, proprioceptive training and swimming leading to a sports- specific training program (return 2-8 wks)

“Sports Medicine for Primary Care Physician’s” “Anterior Cruciate Ligament” • Primary stabilizer to anterior displacement of the tibia on the femur • Secondary role is in the control of rotation of the tibia on the femur and to aide in varus-valgus stability • Common mechanism of injury is a twisting force to the knee accompanied by a varus, valgus, or hyperextension stress to the limb

“Sports Medicine for Primary Care Physician’s” • Clinically feels a “pop” in the knee • Inability to continue to play with a difficult time putting weight on the limb • Gradual onset of swelling over the next 24 hours (acute swelling think chondral fx.) • Examination reveals a positive Lachman Test, positive Drawer sign, and Pivot-Shift sign • Evaluate for other associated injuries

“Sports Medicine for Primary Care Physician’s” “Non-Operative Treatment” • Goal is functional stability • Initially reduce pain and swelling with NSAIDS, PT, and crutches • Immobilization not necessary • Intermediate rehabilitation involves ROM, gait training, strengthening and proprioceptive training

“Sports Medicine for Primary Care Physician’s” • Once effusion down and ROM full, then begin swimming and bicycling followed by light jogging • Late phase rehab includes functional training • Return to sports: 6 to 12 weeks • Must attain 90% of the unaffected extremity strength before return to sports • Bracing is not absolutely indicated (no evidence to support functional bracing)

“Sports Medicine for Primary Care Physician’s” “Anterior Cruciate Ligament” • Isolated disruptions are unusual in children • Two types exist: nontraumatic cruciate insufficiency and post traumatic cruciate insufficiency • Nontraumatic Insufficiency have inherent joint laxity of the knee as well as other joints

“Sports Medicine for Primary Care Physician’s” • Positive anterior drawer sign but firm end point on Lachman test • Findings are seen bilaterally • Athletic participation should be limited • Most will be asymptomatic with activity modification

“Sports Medicine for Primary Care Physician’s”