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
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1 | [footer text here] Objective
▪ Review common problems in sports medicine
▪ Understand basic anatomy of the musculoskeletal system and its clinical correlation to injuries
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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
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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.
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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
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3 | [footer text here] Elbow Anatomy Review
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Elbow XR Review
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4 | [footer text here] Elbow Anatomy Review
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Elbow Anatomy Review
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5 | [footer text here] Elbow Anatomy Review
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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
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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
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Elbow Pain – Diff Dx
▪ If neurological symptoms (weakness, paresthesia); r/o nerve entrapment syndromes
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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.
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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
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8 | [footer text here] Wrist/Hand Anatomy Review
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Wrist/Hand Anatomy Review
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9 | [footer text here] Wrist/Hand Anatomy Review
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Wrist/Hand Anatomy Review
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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
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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.
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11 | [footer text here] Hand Weakness and Numbness – Dx: Carpal Tunnel Syndrome
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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?
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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
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Case – Wrist Pain after a Fall Scapholunate ligament sprain
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13 | [footer text here] Case – Wrist Pain after a Fall Scaphoid fracture
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Case – Wrist Pain after a Fall Triquetrum fracture
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14 | [footer text here] Case – Wrist Pain after a Fall Triangular FibroCartilage Complex tear
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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.
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15 | [footer text here] Case – Wrist Pain after a Fall…check other joints! Radial head fracture
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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.
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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
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Review of Shoulder Anatomy
▪ Layers - Bony articulations (4) - Static stabilizers ▪ Bones, ligaments, capsule, labrum - Dynamic stabilizers ▪ Scapular stabilizers/rotators ▪ Rotator cuff muscles - Bursa
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17 | [footer text here] Shoulder Anatomy Review Bony Articulations
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Shoulder Anatomy Review Bony Articulations
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18 | [footer text here] Shoulder Anatomy Review Static Stabilizers
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Shoulder Anatomy Review Static Stabilizers
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19 | [footer text here] Shoulder Anatomy Review Dynamic Stabilizers
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Shoulder Anatomy Review Dynamic Stabilizers
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20 | [footer text here] Shoulder Anatomy Review Scapular Motion
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Shoulder Anatomy Review Dynamic Stabilizers
▪ Rotator Cuff - Teres minor - Supraspinatus - Subscapularis - Infraspinatus
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21 | [footer text here] Shoulder Anatomy Review Dynamic Stabilizers
▪ Rotator Cuff
- Supraspinatus - Infraspinatus - Teres minor - Subscapularis
- Subscapularis - Supraspinatus - Infraspinatus - Teres minor
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Shoulder Anatomy Review Bursa
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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).
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Possible Xray Findings
Hill Sachs Lesion – Bony Bankart Lesion – Avulsion compression fracture of fracture of glenoid posterior humerus
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23 | [footer text here] Case – Shoulder Dislocation
▪ Labral-only lesions are most commonly repaired via an arthroscopic stabilization procedure where the labrum is fixed back to the glenoid. Bony Bankart lesions may be addressed with open reduction and internal fixation with concomitant labral stabilization.
▪ <1% of RC tears occur in those < 20 yo ▪ There is a 40 to 60% incidence in patients > 40 years old
▪ Physical therapy will help strengthen the dynamic stabilizers. However, there is a >90% recurrence if < 20 years old; only 14% recurrence if > 40 yrs old
Minagawa et al J Orthop 2013, Familiari et al ICJR 2014
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Case – Shoulder Pain
▪ 55 yo RHD female with onset of right shoulder pain one year ago when playing tennis
▪ Had been “getting along” with it and controlling symptoms but began to notice gradual loss of motion despite ice and NSAIDs
▪ Now presenting with pain all the time, including night pain, with inability to sleep on shoulder due to pain
▪ She has had to buy new bras that clasp in front
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24 | [footer text here] Case – Shoulder Pain What is your next step with your patient?
A. Refer to PT if her ROM doesn’t improve with an aggressive HEP at 1 mo F/U
B. Control other comorbid conditions like HTN and hyperlipidemia that predispose her to this problem
A. Refer her to ortho for surgical manipulation under anesthesia
B. Cortisone injection
C. None of the above
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Case: Shoulder Pain Adhesive Capsulitis
▪ Spontaneous, gradual onset of shoulder stiffness and pain caused by tightening of joint capsule
▪ 70% female, 40-60 yoa
▪ Comorbid conditions include diabetes, hypothyroid dz, RA
▪ Can occur after shoulder immobilized or subconscious restricted motion after minor injury or ???
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25 | [footer text here] Case: Shoulder Pain Adhesive Capsulitis
▪ IR/ADDuction first to go and last to come back ▪ Scapular substitution ▪ End range pain ▪ Disuse atrophy
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Natural History of Adhesive Capsulitis
▪ 0-3 months “gradual onset” - painful ▪ 2-9 months “ freezing” ▪ 4-12 months “ frozen” ▪ 5-26 months “thawing” “The art of medicine ▪ Usually self-limited consists of amusing the patient while nature cures the disease.” Hannafin & Chiaia, Clin Orthop Rel Res, 2000
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26 | [footer text here] Treatment of Adhesive Capsulitis
▪ Pain management (+/- sling) ▪ Education and reassurance ▪ Active home stretching program ▪ Physical Therapy ▪ Oral NSAIDs (or steroids)
▪ Glenohumeral injection- capsular distension ▪ Rarely needs surgery (examination/manipulation under anesthesia or arthroscopic lysis of adhesions)
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Steroid injection?
▪ RCT showed intraarticular steroid injection provided better pain relief in the first 8 weeks than NSAIDs. ▪ However, no difference seen in range of motion or pain after 12 weeks ▪ Results similar to other non-controlled studies
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27 | [footer text here] Case – Ankle injury
▪ 16 yo female playing in basketball game and turned her ankle inwards after a rebound when she came down on another foot
▪ Felt a pop; was unable to bear weight
▪ Immediate swelling on the outside and front of ankle
▪ Able to limp into your exam room the next day; points to her lateral ankle as the area of most pain
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Case – Ankle injury
Which is the following is an indication to order X-Rays?
A. Feeling or hearing a pop
B. Inability to walk for 4 steps immediately after the injury
C. Any bruising along the lateral and/or medial malleolus
D. Tenderness on palpation along posterior edge of medial malleolus
E. Numbness around the area of swelling
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28 | [footer text here] Case – Ankle injury
Which is the following is an indication to order X-Rays?
A. Feeling or hearing a pop
B. Inability to walk for 4 steps immediately after the injury
C. Any bruising along the lateral and/or medial malleolus
D. Tenderness on palpation along posterior edge of medial malleolus
E. Numbness around the area of swelling
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Ankle and Foot Anatomy- Bones
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29 | [footer text here] Ankle and Foot Anatomy- Ligaments
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Ankle and Foot Anatomy- Anterior
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30 | [footer text here] Ankle and Foot Anatomy-Lateral
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Ankle and Foot Anatomy-Medial
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31 | [footer text here] Ankle and Foot Anatomy-Posterior
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Case – Ankle injury Ottawa Ankle and Foot Rules
▪ Inability to weight bear immediately and in the emergency / office (4 steps)
▪ Bone tenderness at the posterior edge of the medial or lateral malleolus (Obtain Ankle Series)
▪ Bone tenderness over the navicular or base of the fifth metatarsal (Obtain Foot Series)
Sens 97%, Spec 31-63%, NPV 99%, PPV <20%
Bachmann LM et al BMJ 2003
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32 | [footer text here] Ottawa Ankle and Foot Rules
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Case – Foot Injury
▪ 45 yo female at the climbing gym, slipped and lost her footing and landed awkwardly from ~4 feet
▪ Could bear weight but painful to push off. R foot became more swollen than L
▪ Went to urgent care and told x-rays normal, stay off feet for weekend, given crutches
▪ Comes to see you on Monday as still hurts to walk
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33 | [footer text here] Case – Foot Injury
Of the following, what is the most important question to ask?
A. How many times a day have you been icing?
B. Were you lying down or standing for your X-rays?
C. Have you been keeping it wrapped in a compression type of bandage?
D. Would you feel more comfortable in a walking boot?
E. Are you having pain when driving?
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Case #2 – Foot Injury Lisfranc ligament sprain
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35 | [footer text here] Case – Ankle injury
▪ A 24-year-old professional athlete presents to you with acute-onset right ankle pain and an inability to bear weight. You note significant edema and ecchymosis of the affected ankle.
▪ She states she had a similar injury to her left years ago. Xrays were already obtained, with left ankle for comparison since she reported the prior injury. You decide to take a look at the xrays first before examining her.
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Case – Ankle injury
What is your diagnosis?
A. grade 1 ankle sprain B. grade 2 ankle sprain C. grade 3 ankle sprain D. bimalleolar ankle fracture
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36 | [footer text here] Normal Ankle X-Ray
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Evaluate entire fibula
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37 | [footer text here] Case – Ankle injury Grade 3 ankle sprain
▪ Grade 1 injury involves ligamentous stretching without grossly evident tearing or joint instability. ▪ Grade 2 injury involves a partial tear of a ligament with moderate joint instability; it is often accompanied by significant localized swelling and pain. ▪ Grade 3 injury involves a complete tear of a ligament with marked joint instability and severe edema and ecchymosis.
Rose NG, Green TJ. Ankle and foot. In: Walls R, et al, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018:634-658.e3.
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Case – Ankle/Foot Injury
▪ 34 yo male, enjoys walking and hiking, recently joined his work softball league
▪ First game of the season and hit a grounder; while sprinting to first base, he felt a rock hit the back of his lower leg and he stumbled and fell. His teammates heard a pop. Needed assistance to get to the bench
▪ Iced, elevated, ACE wrap and NSAID
▪ He could walk as long as he kept the ankle stiff; wore his hiking boots to come see you
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38 | [footer text here] Case – Ankle Injury
What is the most likely injury based on his history?
A. Anterior cruciate ligament (ACL) tear B. Achilles tendon tear C. Posterior tibialis tendon tear D. Calf tear E. Plantar fasciitis tear F. B and C G. B and D H. B and E
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Case – Ankle Injury Achilles tendon tear and Calf tear
Thompson test
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39 | [footer text here] Case – Ankle Injury Posterior tibialis tendon tear
Too
Too many toes sign
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Case – Knee Injury
▪ 40 yo female joined a gym in January with her competitive sister-in-law
▪ Began working with a personal trainer and they started a program of Olympic lifting (squatting, cleans) and plyometrics (box jumps)
▪ After 2 weeks began having left knee pain after workouts but continued training
▪ Now seeing you 2 weeks later because now it hurts during training and even with walking, especially on the stairs
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40 | [footer text here] Case – Knee Injury
What is the Least likely diagnosis?
A. Patellofemoral syndrome B. Patellar tendinitis C. Pes anserine bursitis D. MCL sprain E. ITB syndrome F. Hamstring strain
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Patellofemoral Pain
▪ Will point to kneecap region
▪ Pain associated with - running, lunging, squats - sitting for prolonged period - going down stairs (may be worse than up stairs)
▪ Soft tissue swelling often described as puffiness
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41 | [footer text here] Patellofemoral Pain
▪ Thomas test to evaluate tight hip flexors, quads, ITB
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Patellofemoral Pain
▪ Positive patellar compression test ▪ Pain on palp of medial facet of patella ▪ Increased patellar mobility
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42 | [footer text here] Patellofemoral Pain
▪ Double and Single Leg Squat to evaluate for weak quads, gluts
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Patellar Tendinitis
▪ Pain with - resisted knee extension - resisted straight leg raise - single leg squat
▪ May have swelling at inferior pole of the patella
▪ Tenderness at prox patellar tendon
▪ Osgood Schlatters
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43 | [footer text here] Pes Anserine Bursitis
▪ Primary flexors of the knee
▪ Protects knee against rotatory and valgus stress
▪ Pain often acute
▪ Can occur with sports and exercise
▪ Can also occur in sedentary
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Iliotibial Band Syndrome
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44 | [footer text here] Hamstring Strain
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Case – Knee Pain
▪ 65 yo male with h/o medial meniscectomy R knee 20 yrs ago
▪ Reports moderate pain medial knee and general swelling since hiking last weekend
▪ Denies locking and instability, no AM stiffness
▪ On your exam, he has moderate effusion, but no warmth. There is crepitus with range of motion. He is tender at the medial joint line and above/below medial joint line on the medial femoral condyle and medial tibial plateau. McMurrays testing is negative, but knee feels tight with squatting. You don’t find any ligamentous laxity
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45 | [footer text here] Case – Knee Pain
What do you recommend at this time?
A. Refer to an ortho surgeon to consult on knee replacement surgery
B. Order an MRI of the knee to evaluate need for surgical intervention
A. Refer to an orthopedic surgeon for surgical debridement and lavage (“clean it up”)
A. Perform a cortisone injection to help with the pain and swelling
B. Refer to physical therapy and encourage weight loss
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What is OA? What parts of the knee joint are affected?
Disease of the entire synovial joint and multifactorial, including joint degeneration, intermittent inflammation, and peripheral neuropathy
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46 | [footer text here] How do you classify severity of Knee OA?
▪ Kellgren and Lawrence System for classification of knee OA
Kellgren and Lawrence, Ann Rheum Dis 1957
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How do you classify severity of Knee OA?
▪ Kellgren and Lawrence System for classification of knee OA - Grade 0 -- None - Grade 1 -- Minor – usually no pain or discomfort - Grade 2 -- Mild – pain after long day of running/walking, some stiffness after immobile, sore when kneeling or bending - Grade 3 -- Moderate – frequent pain, joint stiffness, some swelling - Grade 4 -- Severe – great pain when walking or moving the knee
Kellgren and Lawrence, Ann Rheum Dis 1957
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47 | [footer text here] What about an MRI to diagnose OA?
▪ MRI in the setting of OA will ALWAYS show a meniscus tear - Patients will get fixated on the meniscus tear - Likely will want to undergo surgery - Unclear how much benefit
▪ Indications for ordering an MRI - Obvious and significant injury (especially in younger patients) - Associated severe effusion - Locking of the knee (can’t straighten or bend) - Non-operative treatments have failed
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Interventions
▪ AKS (irrigation with saline and “clean-up”) - Compared to Control group (PT/medical therapy) - Significant improvement at 3 months with surgery (~ past studies involving sham surgery), but thereafter, no difference in WOMAC scores
▪ Intraarticular cortisone injection vs. placebo injection - Low quality evidence with inconclusive results re: pain relief, improved function, and duration of steroid effect - Q3 month RCT--IA TAC vs saline inj under US - Signif more cartilage loss in TAC group; no signif diff in pain
Kirkley et al, NEJM 2008; Juni et al, Cochrane Library 2015; McAlindon et al, JAMA 2017
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48 | [footer text here] PT, Exercise and Strength Training
▪ Almost everyone will have some weakness and/or functional limitations or imbalances that can be corrected
▪ The most effective PT interventions are exercise: aerobic, aquatic, strengthening, and proprioception - Evaluation of strength and gait - Closed chain exercises - Low to Non-impact aerobic exercise
▪ bike, elliptical, swimming, H2O rehab/exercises - Joint capsule and muscle stretches - Modalities as needed - Daily home exercise and rehab self-management programs
Wang, AIM 2015; https://www.aaos.org/research/guidelines/oaksummaryofrecommendations.pdf
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Weight Management - For every 1 lb weight loss, 4-6 lb in force on the knee per step - Pain reduction with even minimal weight loss - Exercise alone without dietary changes not as effective - Markers of cartilage turnover and breakdown are decreased after bariatric surgery
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49 | [footer text here] Join us in December 14th Annual UCSF Primary Care Sports Medicine Conference December 12- 14, 2019 Intercontinental San Francisco
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Join us on Saturday, January 11th
@ Cal Memorial Stadium
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50 | [footer text here] UCSF Musculoskeletal Exam Tutor App
▪7 musculoskeletal cases ▪> 60 high quality exam videos performed by UCSF experts ▪Apple app store -Search UCSF Musculoskeletal Exam App ▪$20 ▪iOs (Apple) devices only
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Check out our sports rehab guide for patients! https://sportsrehab.ucsf.edu/
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51 | [footer text here] Questions?
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