Southwest Conference on Medicine

May 4, 2019

Geoffrey Landis, DO Tucson Orthopedic Institute University of Arizona Sports Medicine Team Fellowship Trained –Foot and Ankle Orthopedic Surgeon The Role of Orthopaedic Surgery in Sports Related Injuries The Role of Orthopaedic Surgery in Sports Related Injuries

Backround: University of Texas 1994 – Undergrad (ACL, MCL, PCL, Medial Meniscus, Ankle Sprain, AC Sprain, Skiers Thumb) TCOM-2000 (Gastrocnemius Strain, Hamstring Strain,) Doctors Hospital Orthopedic Residency 2005 ( DeQuervains,) Foot & Ankle Fellowship 2006 – OSU – 13 years Practice Tucson Orthopedic Institute ( Medial& Lateral Epicondylitis, Achilles tendonitis, Peroneal tendonitis, Biceps tendonitis) 11 Years – Consultant University of Arizona Sports Medicine Objective

Learn to recognize urgent and emergent musculoskeletal injuries

Improve comfortability and capability of treatment of common sports/MSK injuries

What tests to order & When to refer Overview

Pediatric Injuries Upper Extremity injuries: Shoulder, Elbow, Lower Extremity Injuries: Hip, Knee, Foot & Ankle Pediatric Injuries

• 35 million kids in sporting activities • Last 20 years increase in sporting injuries in kids • 30-50 % injuries due to overuse • Acute Trauma • Fractures • Sprains / Strains Pediatric Overuse Injuries

• Large increase in single sport athletes • Personal coaches/specialized training • Avid Parents • Club teams • Summer Camps Pediatric Overuse Injuries

• Too rapid progression in training • Poor footwear/equipment • Poor Technique • Psychological Factors (maturity, self esteem, parents) Evaluation

• IMPORTANT TO RULE OUT • INFECTION • STRESS FRACTURE • TUMOR Pediatric Overuse Injuries

• GENERALLY PRESENTS WITH • CAUSE- GRADUAL ONSET OF PAIN WITH • RAPID BONE GROWTH EXCEEDS OUT SPECIFIC INJURY ABILITY OF MUSCLE TENDON UNIT TO STRETCH SUFFICENTLY • DX USUALLY ON HISTORY AND • EXAM LESS FLEXIBILITY • MORE TENSION ON THE APOPYSIS • XRAY TO HELP RULE OUT • WORSENED BY ANATOMY/ TUMOR ETC IMPROPER TECHNIQUE/ • GENERAL TREATMENT • REST, NSAIDS, STRETCHING, PT • PARTICIPATION IF NO PAIN W AMBULATION Little League Shoulder

• APOPHYSITIS OF THE PROXIMAL HUMERUS PHYSIS • PAIN W THROWING • COMPARISION XRAY CAN SHOW WIDENED PHYSIS • 4 WKS REST IF NO WIDENING • 3 MONTHS REST IF WIDENING PRESENT Little League Elbow

MEDIAL ELBOW PAIN DECREASED VELOCITY AND CONTROL PAIN/TENDERNESS OVER MEDIAL EPICONDYLE XRAY – MAY SHOW OCD REST 4-6 WEEKS Osgood-Schlatter

APOPHYSITIS OF THE TIBIAL TUBERCLE AGES 8-13 GIRLS/ 11-15 BOYS CAN BE INITIATED BY INJURY QUAD/HAMSTRING TIGHTNESS OK TO PARTICIPATE IN SPORTS SELF LIMITING PT/STRETCH/NSAIDS SINDING-LARSEN-JOHANNSON

APOPHYSITIS OF THE INFERIOR POLE OF THE PATELLA SIMILAR TO OSGOOD SCHLATTER SELF LIMITING TREAT WITH NSAIDS, THERAPY, STRETCHING VERY COMMON APOPHYSITIS OF THE CALCANEUS USUALLY AGES 8-13 PAIN IN POSTERIOR HEEL – BOTH MEDIALLY AND LATERALLY TIGHTNESS OF ACHILLES TENDON TREAT WITH NSAIDS, PT, ICE MORE SEVERE CASES TREATED WITH BOOT TRACTION APOPHYSITIS OF 5TH METATARSAL BASE TENSION FROM PERONEUS BREVIS TENDERNESS ON LATERAL FOOT ENLARGMENT/SWELLING SIMILAR TREATMENT Slipped Capital Femoral Epiphysis (SCFE)

Hip pain & knee pain • - it occurs most often in boys 10-17 yrs ; females, the average age is 12 years bilateral involvement in about 1/3 of pts, loss of internal rotation and/or tenderness of internal rotation • Xray – AP/ Frog Lateral – bilateral hips • Refer to Ortho Slipped Capital Femoral Epiphysis (SCFE) Perthes Disease (LCP)

Hip pain 4-10 yrs of age Boys 5x more likely 10-20% bilateral Pain in hip with running Altered gait Decreased abduction, IR Perthes

Xray- AP/ Frog lateral Refer to pediatric ortho Multiple treatment options depending on staging of disease Shoulder Injuries

• A/C Sprain (Separated Shoulder) • Shoulder Dislocation • Clavicle Fracture • Rotator Cuff Injury Acromio-Clavicular Sprain

• Grade I – the AC ligament is sprained but not torn, no displacement of the clavicle and acromium. • Grade II – the AC ligament is torn, slight displacement of the clavicle causing anterior-posterior instability. • Grade III – AC and coracoclavicular (CC) ligaments torn, up to 100% displacement of the clavicle and therefore both verticle and horizontal instability. • Grade IV – AC and CC ligaments torn but there is also associated tears of the surrounding fascia. • Grade V – AC and CC ligaments torn, associated tear of the surrounding fascia and vertical displacement of 100- 300%. • Grade VI – AC and CC ligaments torn, associated tear of the surrounding fascia and an inferiorly displaced clavicle. Acromio-Clavicular Sprain Acromio-Clavicular Sprain Fall/Direct Blow to Shoulder Pain with palpation over A/C joint Pain with abduction >90

Type I-II Non surgical care Type III refer for discussion of treatment options Type IV-VI Surgical treatment usually necessary Shoulder Dislocation Shoulder Dislocation

• mechanism of anterior dislocations: - combination of abduction, extension, and a posteriorly directed force applied to the arm; - humeral head is driven anteriorly, tearing capsule, detaching labrum from glenoid, and producing a compression fracture of humeral head

• Very Common injury • Likely presents to ER Shoulder Dislocation

For young adults, the rate of re-dislocation ranges from 55 to 95% First time dislocation usually treated non- operatively Sling, rest, PT, pain control

Consider referral to Ortho for long term management options For recurrent instability Clavicle Fracture Clavicle Fracture

• Nonoperative treatment is preferred for nearly all acute, nondisplaced midshaft clavicle fractures • Displaced midshaft clavicle fractures may be managed nonoperatively, but plate fixation should be considered. • Nonoperative treatment is preferred for distal clavicle fractures because outcomes are the same whether or not bony union is achieved. Rotator Cuff Injury

• Overuse injury – overhead arm activity • Pain at night, with overhead activity, • Subacute, but aggravated with sports • Very common • Start with basic care • NSAIDS, PT, Rest, Modify Activity • After failure of initial care- refer for further workup Elbow Injuries

• Biceps Tendon Rupture • Triceps Tendon Rupture • Elbow Dislocation • Medial Epicondylitis • Lateral Epicondylitis Biceps Tendon Rupture

• Distal biceps may rupture off the radial tuberosity; - presents w/ painful swollen elbow usually in a 50- 60 yo active male, most often in the dominant side (uncommon in women);

single traumatic event involving flexion against resistance, w/ elbow at a right angle results in a sudden sharp tearing sensation (eccentric loading) consequences of loss of strength: - 30 % decrease in flexion strength; - 40 % loss of supination strength Biceps Tendon Rupture

Exam: - weakness of flexion and supination; - carefully palpate for a residual biceps tendon in the antecubital fossa

Refer to Ortho for Discussion of Surgical vs Non-op Care

Non op care results: supination decreases by 50% where as flexion strength will decrease by 35-40%; decrease in endurance strength averages 40% Triceps Tendon Rupture Rare Direct Blow to elbow in flexion or forceful eccentric contraction Associated with Marfans, Hypothyroidism Loss of extensor strength Surgery required for repair Elbow Dislocation • dislocations of elbow usually result from fall onto extended elbow • elbow dislocation is the second most common major joint dislocation; - dislocation is usually closed and posterior • elbow dislocations without fracture are termed simple. whereas dislocations with fracture are termed complex • Can have associated nerve injuries 15-20% Presents usually to ER for acute treatment Medial Epicondylitis

• GOLFERS ELBOW • tenderness over the origin of the forearm flexors; - resisted pronation and/or flexion will elicit pain in most patients; - grip strength is usually be impaired • Overuse injury • Treat non-operatively • NSAIDS, PT, counterforce brace, injection Lateral Epicondylitis

• TENNIS ELBOW • tenderness over the origin of the forearm extensors; pain elicited with elbow in extension, forearm in pronation, and wrist in flexion • grip strength in pronation is usually be impaired • Overuse injury • Treat non-operatively • NSAIDS, PT, counterforce brace, injection Hip/Groin Injuries

Primarily Muscle Strains Treat with RICE NSAIDS PT Avoid explosive movement/ plyometric activity for 6 weeks Muscle Strain

Hamstring Strain Hip Flexor Strain Adductor Strain

Knee injuries

• Ligament injuries • Meniscus/Chondral injuries • Patellar dislocation • Patellar tendon rupture • Quadriceps tendon rupture • Prepatellar bursistis Knee Ligament Injuries

• ACL • PCL • MCL • LCL • Knee effusion • Decreased ROM • Test individual ligaments with PE Knee Ligament Injuries

• Treatment: • Immobilize • MRI • ?Aspirate • Lateral suprapatellar approach Meniscus/Chondral injuries

Twisting injury Knee effusion Joint line pain “Bucket handle tear” locked knee/ limited ROM Rest, PT, NSAIDS MRI – ?Surgery - Patellar dislocation

• Usually lateral displacement of patella • Occurs most often 10-30 yrs old • Associated with ligamentous laxity; increased Q angle, dysplastic trochlea, muscle weakness

Treat: Reduce dislocation Immobilize Imaging for possible osteochondral injury Xray- post reduction MRI Patellar Tendon Rupture

• usually occur in pts under age of 40; - most ruptures occur w/ the knee in a flexed position (around 60 deg) which are then subject to excessive loading; - great majority occur at level of inferior patellar pole (> level of tibial tubercle) • High riding patella • Palpable defect • Inability to extend knee • Requires surgical treatment Quadriceps tendon rupture

• Often > 40 yrs old • Associated with DM, Renal disease, RA • Palpable defect superior to patella • Loss of knee extension • Patella baja/ low riding patella • Immobilize • Requires surgical treatment Pre-Patellar Bursitis

• Direct injury to patella – “Housemaids knee” • Concerns if infected • Swelling / edema btwn skin/ patella • Aspirate? • ABX • Refer if concerned / fails initial abx regimen Foot and Ankle Injuries

Ligament Injuries Chondral Injuries Achilles Rupture Tendonopathies Lisfranc Injury Turf Toe Stress fractures Foot and Ankle Injuries

• OTTOWA RULES - ANKLE • Ankle X-ray is only required if there is any pain in the malleolar zone and any one of the following: • Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus, OR • Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus, OR • An inability to bear weight both immediately and in the emergency department for four steps Foot and Ankle Injuries

Ankle Sprain Injury to ATFL, CFL, capsule, rarely medial injury Can take months to fully heal RICE, WBAT in boot, PT after a few weeks of rest If no improvement – MRI Associated problems: Subtle fracture, OCD, Tendon injury, Foot and Ankle Injuries

Osteochondral Fractures: Rare Best treated Surgically Achilles Rupture

Sudden pop in back of ankle “kicked” Can still walk Palpable defect Weakness

Thompson Testif tendon is intact, the foot will plantar flex, & conversely if tendon is ruptured, the foot will not contract; Refer- MRI overutilized Other Ankle Tendonopathies

Peroneal Tendonitis/Tear Posterior Tibial Tendonitis/Tear Os Trigonum/ FHL Tendon Anterior Tibial Tendonitis Other Ankle Tendonopathies

Peroneal Tendonitis/Tear Other Ankle Tendonopathies

Posterior Tibial Tendonitis/Tear Other Ankle Tendonopathies

Os Trigonum/ FHL Tendon Other Ankle Tendonopathies

Anterior Tibial Tendonitis/ Rupture Lisfranc Injuries

• Can often be subtle • Pain in midfoot • Consider ordering comparison xrays • Best if standing xrays • MRI / Immobilize if inconclusive • Long healing time/ high potential for complications Turf Toe

• turf toe is a tear of joint capsule from MT head which results in subluxation or dislocation of first MTP joint

• RICE, NSAIDS, Boot/Post op shoe • Surgical repair in athletes often performed Stress Fractures Thank you

Questions