Implement Evidence-Based Strategies in the Care of Patients Who Sustain

Conflict of Interest

Care of the Patient with an I hereby certify that, to the best of my knowledge, no aspect of my current Orthopaedic Sports Injury personal or professional situation might reasonably be expected to affect significantly my views on the subject on Bryan Combs, MSN, FNP‐BC, CNL, ATC which I am presenting other than the following:

Learner Outcome Sports Medicine

• Sports medicine, also known as sport and Implement evidence‐based exercise medicine, is a branch of medicine strategies in the care of that deals with physical fitness and the treatment and prevention of injuries related patients who sustain sports to sports and exercise related injuries

1 The Sports Medicine Team The Sports Medicine Team

Athlete Athlete

Athletic Athletic Trainer Trainer

NP/Doctor Coach NP/Doctor Coach

Understand the Setting Understand the Sport

• The Sideline • They each have specific aspects that you must know • The Training Room – Required equipment • The Office – Contact vs Non‐Contact – How far apart are games • This is critical for planning care

2 What Are the Expectations Return To Play: Risk vs Reward

• This is a difficult balance • What is the typical treatment plan? • There can be a lot of voices • What is the goal of the athlete? – Athlete, Coach, Parents, etc. • Are they hurt or are they injured? • Must keep the health of the patient as the • Can they make the injury worse? primary goal • Can they be protected? • Risk vs Reward • Where are they in the season and what is their unique situation?

Not the Typical Pharmacology The Basics – H.O.P.E. • History • NSAIDs • Muscle Relaxers – With good history you will likely know what is – ketorolac, Ibuprofen, – cyclobenzaprine or going on before you even touch the PT naproxen, and ASA methocarbamol • Observation • Concern is ulcers and • Can be sedating gastric bleeding • Difficult in sports – Swelling, Bruising, and Gait • Oral, Topical, • Corticosteroids • Palpate for Pain Injectable – Prednisone – Helps isolate injury –Biggest key to physical exam – Cox‐2 Inhibitors – – Often used as injection celecoxib • Evaluation • Pain relievers • risks of heart attacks – ROM, Strength, and Special Tests – and strokes acetaminophen and hydrocodone

3 The Basics – R.I.C.E. Common Injuries • Rest • Compression – Need to allow time – To decrease swelling • Tendonitis • Knee to recover – Ace wrap or tape • Strains – ACL – Especially for chronic – MCL or Tendonitis • Shoulder • – Impingement • Ankle Ice • Elevation – – Lateral Ankle First 72 hours – Above level of the • Hand/Wrist Sprain – Then transition to heart – Scaphoid Fracture heat – High Ankle Sprain – Mallet Finger – Always at end of day, work, or sports.

Tendonitis Tendonitis

• History • Physical Assessment • Treatment – Overuse injury – MMT all ROM of – REST REST REST – Location specific to affected area – Splinting if significant activity and sport – Pain with MMT – When returning to – Pain worse with active – Typically no pain with activity must work motion passive motion slowly and in gradual – Typically will have – Use palpation to locate manner insidious onset most significant area – Steroid Injections often – May accompany change used but proceed with in activity or position caution and must educate patient no to return to early

4 Strains Strain • History • Physical Assessment • Treatment – Acute injury – MMT all ROM of – Location specific to affected area – RICE activity and sport – Pain with MMT – Once calm must improve ROM then work on strength – Pain worse with active – Typically pain with motion but also passive passive motion when – When returning to activity motion getting to a stretch must work slowly and in gradual manner – Typically will have – Use palpation to locate sudden onset most significant area – Steroid Injections often used – Felt a pop or was hit by but proceed with caution and sniper must educate patient not to return too early

Question 1 Football • Which of the following is the most • Scaphoid Fracture important when considering treatment for tendonitis? • Stingers A. Compression • AC Joint Separations B. Heat • LisFranc Sprain C. Rest • MCL tear D. Acetaminophen • High Ankle Sprain

5 Scaphoid Fracture Scaphoid Fracture • History • Physical Exam – Almost always acute – Point tender in anatomic snuff – Fall on outstretched box – X-Rays of wrist with scaphoid hand view

If pain here assume scaphoid fracture until proven otherwise

Scaphoid Fracture Question 2

• Treatment • When should you schedule a follow up – Place in thumb spica cast or full time thumb spica splint appointment with a patient whose x‐rays are – Follow-Up in 10-14 days. X-Ray can take 10 days to show fracture normal but they have pain over their – This bone has poor blood supply and if not treated anatomic snuff box? correctly can lead to long term problems similar to S/L A. 4 days Tears. (SNAC wrist) – Always refer to hand surgeon if diagnosed B. 7 days • Even not displaced will likely have some form of C. 10 days internal fixation D. 16 days

6 Stinger/Stinger Stinger

• History • Physical Assessment • Treatment – Injury to the brachial – Spurling’s test ‐ passively – Increase strength in plexus hyperextends and affected area and neck – Typically due to direct laterally flexes the – Work to use padding or contact to the shoulder patient's neck toward bracing if needed or lateral neck flexion the involved side – This may be recurring – Causes a traction or and this should be a compression of plexus concern and require a – Complaints of weakness, thorough work up burning, tingling, paresthesia

AC Joint Separation AC Joint Separation

• History • Physical Assessment – Injury to the – Positive piano key test Acromioclavicular joint – of the shoulder Point tender over AC joint – This is the roof of the – Most times there is a deformity shoulder joint • Treatment – Connects the shoulder – X‐Ray to verify separation and no fracture blade to the sternum – Place in Figure 8 Brace – Usually Acute – Most common from fall – This needs to be referred mostly will not require or impact onto top of surgery, but let surgeon decide shoulder

7 MCL Tear MCL Tear

• Physical Assessment • History – May have inflammation but not all the time – Similar to ACL – Positive valgus stress test – Common in Sports – Women more susceptible due to Q Angle – Usually happens while planting leg – Will feel and pop and give way – The knee has a valgus force – Can be isolated or with ACL

MCL Tear MCL Tear

• Physical Assessment • Treatment – May have inflammation but not all the time – X‐Rays will likely be negative – Positive valgus stress test – Place in hinged knee brace and on crutches if unable to walk without a limp – Grade 1 ‐ Order PT – Grade 2 or 3 –refer to specialist

8 High Ankle Sprain High Ankle Sprain

• History • Physical Exam – Due to forced Eversion – Point tender at Tib‐Fib causing separation of the Ligament tibia and fibula leading – Must do weight bearing to injury of the Tib‐Fib Bilateral X‐rays looking Ligament for syndesmosis – Very Painful widening – Often Little Swelling

High Ankle Sprain LisFranc Fracture/Sprain

• Treatment • History – Place in boot and make non‐weight – Due to driving foot into bearing/on crutches ground or having – Often will get steroid injection into the Tib‐Fib something fall on heel Ligament – Is usually not a fracture – Needs referral –may need surgery but disruption of the mid‐foot – Not as common but very debilitating

9 LisFranc Fracture/Sprain Basketball

• Physical Exam • Mallet Finger – Pt. Tender in Mid‐foot – Need weight bearing • Jersey Finger bilateral foot x‐rays • Lateral Ankle Sprain • Treatment – Place in walking boot • Jones Fracture and non‐weight bearing – If suspected refer ASAP – May need surgery to repair

Mallet Finger Mallet Finger

• Treatment • History – If no fracture at distal – Common during sports phalanx you can splint or cleaning house 100% of time for 8 weeks. – Rupture of extensor – Finger can never bend tendon of finger at DIP during this time – Causes finger to drop – Needs to follow up with PCP or specialist • Physical Assessment – If any sign of fracture then – Pt. can not extend refer ASAP. It will need to – X-Rays should be taken be pinned to allow bone to heal.

10 Question 3 Jersey Finger

• Which of the following is the most • History appropriate treatment plan for a patient – Forced extension of the DIP joint during active with a bony mallet finger? flexion causing rupture A. Place in full extension for 8 weeks of flexor digitorum profundus tendon B. Place is resting position for 6 weeks – The finger will present C. Schedule for follow up for 2 weeks with DIP extended D. Refer to surgeon for evaluation

Jersey Finger Lateral Ankle Sprain

• Physical Assessment • History – Mainly based on history and presentation – Inversion Injury (Roll In) – Check for flexion at DIP joint – Most common ankle • Treatment sprain – – Splint in a slightly flexed or resting position Stepped of curb, rolled of someone's foot, was – Refer to hand surgeon ASAP just jogging – Many times a lot of swelling and bruising

11 Lateral Ankle Sprain Lateral Ankle Sprain

• Physical • Physical Assessment Assessment – X‐ray usually – X‐ray usually negative negative – Positive Anterior – Positive Anterior Drawer Test Drawer Test – Point tender over – Point tender over Anterior Talo‐ Anterior Talo‐ Fibular Ligament Fibular Ligament

Lateral Ankle Sprain Lateral Ankle Sprain

12 Lateral Ankle Sprain Jones Fracture

• Treatment • History – Fracture of the Base of the 5th – RICE and therapy. Metatarsal –where peroneus brevis attaches – May need a boot to help walk until can walk – Common Fracture with no limp – Can be a Stress FX or Acute FX – Hurts on the outside of the – Refer if no improvement in 1‐2 weeks foot – Often can return to activity with support or tape • Physical Exam – X‐rays are positive for Acute – Must work on proprioception to prevent future but will need MRI for Stress injury FX – Point tender on base of fifth metatarsal

Jones Fracture Jones Fracture

• History • Treatment – Fracture of the Base of the 5th Metatarsal –where peroneus – RICE brevis attaches – Place in walking boot – Common Fracture and non‐weigh bearing – Can be a Stress FX or Acute FX – Hurts on the outside of the – Needs referral once foot diagnosed or suspected • Physical Exam – Surgeon may follow with – X‐rays are positive for Acute rest or prefer surgery to but will need MRI for Stress fix FX – Point tender on base of fifth metatarsal

13 Baseball/Softball Shoulder Impingement

• Shoulder Impingement • History – This is an overuse injury • Rotator Cuff Injury – Shoulder pain with overhead • Labral Tear motion. – Night pain with sleeping on • UCL Tear shoulder. • Hook of the Hamate Fracture – Pain with internal rotation. – Numbness and pain radiation below the elbow are usually due to cervical spine disease.

Shoulder Impingement Shoulder Impingement • Physical Assessment • Physical Assessment – ROM –Flexion, Extension, – ROM –Flexion, Extension, Adduction, Adduction, Abduction, Internal Abduction, Internal Rotation, Rotation, External Rotation External Rotation – Manual Muscle Testing all – Manual Muscle Testing all ROM’s ROM’s • Include the Empty Can Test – • Include the Empty Can Test – Shoulder abducted Shoulder abducted to 90deg then adducted to 90deg then adducted across chest 45deg. Then across chest 45deg. Then pronate arm to put thumb pronate arm to put thumb down as if emptying a can. down as if emptying a can.

14 Shoulder Impingement Shoulder Impingement • Physical Assessment • Physical Assessment – ROM –Flexion, Extension, – ROM –Flexion, Extension, Adduction, Adduction, Abduction, Internal Abduction, Internal Rotation, Rotation, External Rotation External Rotation – Manual Muscle Testing all – Manual Muscle Testing all ROM’s ROM’s • Include the Empty Can Test – • Include the Empty Can Test – Shoulder abducted Shoulder abducted to 90deg then adducted to 90deg then adducted across chest 45deg. Then across chest 45deg. Then pronate arm to put thumb pronate arm to put thumb down as if emptying a can. down as if emptying a can.

Shoulder Impingement Shoulder Impingement

Special Tests Special Tests • X‐Rays – will likely be normal • X‐Rays – will likely be normal • Hawkins–Kennedy • Hawkins–Kennedy Impingement Test Impingement Test – Patient is sitting or standing – Patient is sitting or standing with upper extremities with upper extremities relaxed Examiner grasps the relaxed Examiner grasps the patient's elbow with one patient's elbow with one hand and the patient's wrist hand and the patient's wrist with the other hand with the other hand Examiner forward flexes the Examiner forward flexes the shoulder to 90 degrees° and shoulder to 90 degrees° and then internally rotates the then internally rotates the patient's shoulder Will be patient's shoulder Will be positive if pain positive if pain

15 Shoulder Impingement Rotator Cuff Injury • History – SITS – Supraspinatus, • Treatment Infraspinatus, Teres Minor, Subscapularis – RICE – Can be acute or chronic – Rehab – Will concentrate on rotator cuff and anti‐ – Often associated with Labral inflammatory treatments tear – History of sports or thrower – Injection –You can do a corticosteroid injection – A common cause of shoulder to help decrease inflammation impingement syndrome after age 40. – Difficulty lifting the arm with limited active range of motion. – Weakness with resisted strength testing suggests full thickness tears.

Rotator Cuff Injury Labrum Tear

• History • Physical Assessment – Chronic or Acute – Same as Impingement – Cartilage around glenoid to give more surface area. Think – Will likely diagnose with manual muscle testing Golf Ball on golf Tee • Empty can test is most helpful – SLAP Lesion –most common – History of sports or thrower – MRI Arthrogram – Shoulder must be Arthrogram – A common cause of shoulder impingement syndrome after • Treatment age 40. – Can use rehab for partial tears but I would always refer to – Difficulty lifting the arm with limited active range of let ortho evaluate motion. – Weakness with resisted strength testing suggests full thickness tears.

16 Labrum Tear UCL Tear

• Physical Assessment • History – Same as Impingement – Mostly Athletes – – Will likely diagnose with manual muscle testing throwers or people – Empty can test is most helpful whose work stress – MRI Arthrogram – Shoulder must be Arthrogram medial elbow – Positive O’Brien Test – It is a tear of the Medial – Can be injured with rotator cuff tear or after dislocation or subluxation Collateral or Ulnar • Treatment Ligament – RICE and therapy. If no improvement refer. Most likely will • Tommy John’s Surgery require surgery. – Usually develops – Can use rehab for partial tears but I would always refer to let chronically leading into ortho evaluate an acute injury

UCL Tear UCL Tear

• Physical Assessment • Physical Assessment – Will be point tender in – Will be point tender in medial elbow at the medial medial elbow at the medial epicondyle epicondyle – Positive valgus stress test – Positive valgus stress test – X‐Rays will be negative – X‐Rays will be negative • Treatment • Treatment – Always refer if suspect it. – Always refer if suspect it. Will likely need MRI and Will likely need MRI and surgery. surgery.

17 Fracture Hook of Hamate Fracture Hook of Hamate

• History • Treatment – Fall on outstretched hand of people that use bats or – RICE & NSAIDs brooms – If suspected or diagnosed • Physical Exam refer but does not need to – Point tender in palm be done quickly. – X-Rays need carpal tunnel view. Hard fracture to see. – This will usually not heal – Fracture may not show for and they just excise the 10-14 days. Do not just fragment. assume a sprain or bruise – Place thumb on pisiform and point towards web of thumb.

Soccer Meniscus Tear

• History • Meniscus Injury – C‐Shaped Cartilage in the knee • ACL Tear – Caused by stresses of the knee that pinch the meniscus between the femur and tibia • Valgus, Varus, Anterior or Posterior translation – Commonly associated with ACL tears – Complaints of pain walking up stairs or catching or locking

18 Meniscus Tear Meniscus Tear

• Physical Assessment • Physical Assessment – Pain on Palpation of – Pain on Palpation of joint line joint line – Positive Flexion, – Positive Flexion, Apley, and Apley, and McMurray Tests McMurray Tests – X‐Rays likely normal – X‐Rays likely normal – MRI Arthrogram – MRI Arthrogram

Meniscus Tear Meniscus Tear

• Physical • Physical Assessment Assessment – Pain on Palpation – Pain on Palpation of joint line of joint line – Positive Flexion, – Positive Flexion, Apley, and Apley, and McMurray Tests McMurray Tests – X‐Rays likely – X‐Rays likely normal normal – MRI Arthrogram – MRI Arthrogram

19 Meniscus Tear ACL Tear

• History – Common in Sports • Treatment – Women more susceptible due to Q Angle – Will not heal on own, must be stitched or cleaned up – Usually happens while – RICE and therapy. If no improvement in 2‐4 weeks refer planting leg – Will feel and pop and give for evaluation and possible surgery way – The knee has a valgus force with rotation – Usually has a torn Meniscus and MCL – Refer if suspected or diagnosed

ACL Tear ACL Tear

• Physical Assessment • Physical Assessment – Will have palpable – Will have palpable inflammation inflammation – Positive Anterior Drawer – Positive Anterior Drawer (best test) or Lachman Test (best test) or Lachman Test (hard to do) –both tests (hard to do) –both tests are sliding or pulling the are sliding or pulling the tibia anterior to stress the tibia anterior to stress the ACL. Looking for no end ACL. Looking for no end point point

20 ACL Tear ACL Tear

ACL Tear Question 4 • Treatment • Which of the following tests would be the – X‐Rays will likely be negative most beneficial when assessing a patient for – Place in long leg brace and crutches a possible meniscal injury? – MRI Arthrogram – usually preference of most ortho surgeons A. McMurray’s – If suspected refer B. Lachman’s C. McBurney’s D. Hawkin’s Kennedy

21 References Thank you!

Madden, Putukian, McCary, & Young (2018), Netter's sports medicine, Philadelphia, PA: Elsevier Thompson (2016), Netter's Concise Orthopaedic Anatomy, Philadelphia, PA: Elsevier Magee (2014), Orthopedic Physical Assessment, Philadelphia, PA: Elsevier