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

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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 • Physical • Physical Assessment Assessment – X‐ray usually – X‐ray usually negative negative – Positive Anterior – Positive Anterior Drawer Test Drawer Test –
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