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Your Template! 2019 UCSF Primary Care Medicine Principles and Practice Management of Common Problems in Sports Medicine Cindy J. Chang, M.D. Clinical Professor, Primary Care Sports Medicine Depts. of Orthopaedics and Family & Community Medicine Past President, American Medical Society for Sports Medicine Board of Trustees, American College of Sports Medicine Disclosure ▪ I have no conflict of interest in relation to this presentation ▪ Ossur Americas: independent lectures on osteoarthritis ▪ NeuroSlam: scientific advisor ▪ Agency for Student Health Research: medical advisory board 2 Cindy J. Chang M.D. 1 | [footer text here] Objective ▪ Review common problems in sports medicine ▪ Understand basic anatomy of the musculoskeletal system and its clinical correlation to injuries 3 Cindy J. Chang M.D. History (MS OLDCARTS vs OPQRST) ▪ Mechanism ▪ Symptoms ▪ Onset (O) – date of injury ▪ Location – point to where the pain is ▪ Duration – acute or chronic ▪ Character (Q) – burning, sharp, dull, achy ▪ Aggravating/Alleviating (P) – provokes/palliates ▪ Radiation (R) – come from or go anywhere else ▪ Timing (T) – constant, at night, with activity ▪ Severity (S) – grade pain https://meded.ucsd.edu/clinicalmed/history.htm 4 Cindy J. Chang M.D. 2 | [footer text here] Case - Elbow Pain ▪ Your patient is a 36 yo female recreational tennis player with elbow pain radiating down the posterior aspect of her forearm that has increased over the past two days. She recently began playing tennis on a USTA team that practices nightly. ▪ She has no medical problems. She takes a combination oral contraceptive. Family history is noncontributory. She does not use tobacco, alcohol, or recreational drugs. ▪ She is afebrile with normal vital signs. Examination reveals tenderness distal to the lateral epicondyle, with pain increased with wrist extension against resistance. She has increased pain with resisted supination. 5 Cindy J. Chang M.D. Case - Elbow Pain Which of the following is most appropriate for this patient? A. Opioid analgesics B. Corticosteroid injection C. Counterforce bracing D. Extracorporeal shock wave therapy E. Strength training 6 Cindy J. Chang M.D. 3 | [footer text here] Elbow Anatomy Review 7 Cindy J. Chang M.D. Elbow XR Review 8 Cindy J. Chang M.D. 4 | [footer text here] Elbow Anatomy Review 9 Cindy J. Chang M.D. Elbow Anatomy Review 10 Cindy J. Chang M.D. 5 | [footer text here] Elbow Anatomy Review 11 Cindy J. Chang M.D. Elbow Pain – Dx: Lateral epicondylitis “tennis elbow” ▪ No single treatment is completely effective - Counterforce bracing relieves pain - Strength training, exercise, stretching all decrease pain ▪ RICE: rest, elevation, compression, and elevation ▪ PMM: protection, medication and modalities (physical therapy) ▪ NSAIDs + watchful waiting better than CS injections ▪ CS injection better than PT at 6 wks, worse at 12 wks ▪ PT less pain and better fxn than CS inj or NSAIDs ▪ ECSWT no significant benefit http://www.aafp.org/afp/2000/0201/p691.html http://emedicine.medscape.com/article/96969-medication#4 http://www.ucdenver.edu/academics/colleges/medicalschool/departments/familymed/education/fellowship/sportsmedf ellow/Documents/MS%20exam.pdf 12 Cindy J. Chang M.D. 6 | [footer text here] Elbow Pain – Diff Dx ▪ If mechanical symptoms (locking, catching): r/o intraarticular pathology ▪ If neurological symptoms (weakness, paresthesia); r/o nerve entrapment syndromes 13 Cindy J. Chang M.D. Elbow Pain – Diff Dx ▪ If neurological symptoms (weakness, paresthesia); r/o nerve entrapment syndromes 14 Cindy J. Chang M.D. 7 | [footer text here] Case – Hand Weakness and Numbness ▪ A 31-year-old female gymnastics instructor presents to your clinic with a complaint of right-hand weakness and numbness. ▪ She also works as a receptionist part- time and states that her symptoms are worst at the end of her workday. ▪ On physical examination, there is a loss of sensation along the palmar aspect of her thumb and first two digits. You note atrophy of her thenar eminence as well. 15 Cindy J. Chang M.D. Case – Hand Weakness and Numbness The nerve implicated in her symptoms innervates which of the following muscles? A. Flexor digitorum superficialis B. Adductor pollicis C. Extensor digitorum D. Abductor pollicis longus E. Flexor carpi ulnaris 16 Cindy J. Chang M.D. 8 | [footer text here] Wrist/Hand Anatomy Review 17 Cindy J. Chang M.D. Wrist/Hand Anatomy Review 18 Cindy J. Chang M.D. 9 | [footer text here] Wrist/Hand Anatomy Review 19 Cindy J. Chang M.D. Wrist/Hand Anatomy Review 20 Cindy J. Chang M.D. 10 | [footer text here] Case – Hand Weakness and Numbness The nerve implicated in her symptoms innervates which of the following muscles? A. Flexor digitorum superficialis B. Adductor pollicis C. Extensor digitorum D. Abductor pollicis longus E. Flexor carpi ulnaris 21 Cindy J. Chang M.D. Hand Weakness and Numbness – Dx: Carpal Tunnel Syndrome ▪ Your patient is presenting with carpal tunnel syndrome, which affects the median nerve. It is caused by compression of the nerve by the flexor retinaculum at the palmar surface of the hand. ▪ Symptoms of carpal tunnel syndrome are explained by the distal innervation of the nerve. It supplies sensation to the palmar aspect of the thumb and adjacent 2 radial digits. Moore, KL, et. Al; Clinically Oriented Anatomy. Lippincott, Williams, and Wilkins (2014). Philadelphia, PA. 22 Cindy J. Chang M.D. 11 | [footer text here] Hand Weakness and Numbness – Dx: Carpal Tunnel Syndrome 23 Cindy J. Chang M.D. Case – Wrist Pain after a Fall ▪ A 15-year-old boy presents to the emergency room for wrist pain and swelling after a skateboarding accident. He broke his fall by landing on his wrist while the hand was in an outstretched or hyperextended position (FOOSH). ▪ On physical exam, his wrist is swollen more on the radial side, and there is point tenderness on palpation of the anatomical snuffbox. He also hurts over the distal radius. ▪ The following x-ray image depicts which of the following injuries resulting from this fall? 24 Cindy J. Chang M.D. 12 | [footer text here] Case – Wrist Pain after a Fall A. Scapholunate ligament injury B. Scaphoid fracture C. Triquetrum fracture D. TFCC tear E. Salter-Harris Type 1 fracture distal radius F. Radial head fracture 25 Cindy J. Chang M.D. Case – Wrist Pain after a Fall Scapholunate ligament sprain 26 Cindy J. Chang M.D. 13 | [footer text here] Case – Wrist Pain after a Fall Scaphoid fracture 27 Cindy J. Chang M.D. Case – Wrist Pain after a Fall Triquetrum fracture 28 Cindy J. Chang M.D. 14 | [footer text here] Case – Wrist Pain after a Fall Triangular FibroCartilage Complex tear 29 Cindy J. Chang M.D. Case – Wrist Pain after a Fall Salter-Harris Type 1 fracture distal radius ▪ I – S = Straight across. Fracture of the cartilage of the physis (growth plate) ▪ II – A = Away from joint. The fracture is through and into the metaphysis, or Away from the joint. ▪ III – L = Leading to joint. The fracture is through and into the epiphysis, Leading to the joint. ▪ IV – TE = Through Everything. The fracture is through the metaphysis, physis, and epiphysis. ▪ V – R = Rammed (crushed). The physis has been crushed. 30 Cindy J. Chang M.D. 15 | [footer text here] Case – Wrist Pain after a Fall…check other joints! Radial head fracture 31 Cindy J. Chang M.D. Case – Shoulder Dislocation ▪ A 20-year-old right-hand-dominant man presented to the Emergency Department following a traumatic dislocation of his right shoulder that was self-reduced when surfing. Physical exam revealed an intact axillary nerve with intact neurovascular status distally. ▪ Prior to presenting to your office, he had dislocated two more times. A family friend was able to get him an MRI and he brings in the CD but you are still waiting for the faxed report. He comes to you for advice as his family physician. 32 Cindy J. Chang M.D. 16 | [footer text here] Case – Shoulder Dislocation ▪ What do you think will be the next best step in management? A. Shoulder immobilizer and serial radiographs B. Bankart repair for surgical stabilization C. Surgical repair of a rotator cuff tear D. Physical therapy E. Learn how to become left handed 33 Cindy J. Chang M.D. Review of Shoulder Anatomy ▪ Layers - Bony articulations (4) - Static stabilizers ▪ Bones, ligaments, capsule, labrum - Dynamic stabilizers ▪ Scapular stabilizers/rotators ▪ Rotator cuff muscles - Bursa 34 Cindy J. Chang M.D. 17 | [footer text here] Shoulder Anatomy Review Bony Articulations 35 Cindy J. Chang M.D. Shoulder Anatomy Review Bony Articulations 36 Cindy J. Chang M.D. 18 | [footer text here] Shoulder Anatomy Review Static Stabilizers 37 Cindy J. Chang M.D. Shoulder Anatomy Review Static Stabilizers 38 Cindy J. Chang M.D. 19 | [footer text here] Shoulder Anatomy Review Dynamic Stabilizers 39 Cindy J. Chang M.D. Shoulder Anatomy Review Dynamic Stabilizers 40 Cindy J. Chang M.D. 20 | [footer text here] Shoulder Anatomy Review Scapular Motion 41 Cindy J. Chang M.D. Shoulder Anatomy Review Dynamic Stabilizers ▪ Rotator Cuff - Teres minor - Supraspinatus - Subscapularis - Infraspinatus 42 Cindy J. Chang M.D. 21 | [footer text here] Shoulder Anatomy Review Dynamic Stabilizers ▪ Rotator Cuff - Supraspinatus - Infraspinatus - Teres minor - Subscapularis - Subscapularis - Supraspinatus - Infraspinatus - Teres minor 43 Cindy J. Chang M.D. Shoulder Anatomy Review Bursa 44 Cindy J. Chang M.D. 22 | [footer text here] Case – Shoulder Dislocation B. Bankart repair ▪ Your 20 yo patient likely has a Bankart lesion in the setting of a first time traumatic dislocation and now resultant instability of the glenohumeral joint due to the Bankart lesion. ▪ This requires surgical stabilization. ▪ A Bankart lesion may involve only the labrum or the labrum plus a bony portion of the glenoid (bony Bankart). 45 Cindy J. Chang M.D. Possible Xray Findings Hill Sachs Lesion – Bony Bankart Lesion – Avulsion compression fracture of fracture of glenoid posterior humerus 46 Cindy J.
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