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Common Problems in Sports Speaker Disclosure: Medicine Update and Pearls for Practice Founder, RunSafe™

Anthony Luke MD, MPH, CAQ (Sport Med) Founder, SportZPeak Inc. Benioff Distinguished Professor in Sports Medicine Director, Primary Care Sports Medicine, Departments of Orthopedics & Family & Community Medicine University of California, San Francisco Sanofi, Investigator initiated grant

May 25, 2017

Overview Acute Hemarthrosis §Highlight common presentations 1) ACL (almost 50% in children, >70% in adults) 2) Fracture (, tibial plateau, Femoral supracondylar, § Physeal) § 3) Patellar dislocation § §Concussion § Unlikely meniscal lesions §Discuss basics of conservative and surgical management Emergencies Urgent Orthopedic Referral

1. Neurovascular injury §Fracture 2. §Patellar Dislocation • Associated with multiple injuries “ ” (posterolateral) § Locked - unable to fully extend the knee (OCD or Meniscal tear) • High risk of popliteal artery injury §Tumor • Needs arteriogram 3. Fractures (open, unstable) 4. Septic

Anterior Cruciate Ligament (ACL) What is True About ACL Tears? Tear Mechanism 1. An MRI is the best test to diagnose the ACL §Landing from a 2. The medial meniscus is most commonly torn jump, pivoting or with an ACL tear decelerating 3. All patients with an ACL tear are better off suddenly getting reconstruction vs non-op treatment § fixed, valgus 4. Athletes can expect full recovery after ACL stress reconstruction Anterior Cruciate Ligament (ACL) ACL physical exam Tear LOOK §Effusion (if acute) FEEL Symptoms §“O’Donaghue’s ” §Audible pop heard or felt = Medial , MCL §Pain and tense swelling in injury, ACL tear minutes after injury §Lateral meniscus tears more common than medial §Feels unstable (bones shifting or giving way) §Lateral joint line tender - femoral condyle bone bruise MOVE

Double fist sign §Maybe limited due to effusion or other internal derangement

Special Tests ACL X-ray

§Lachman's test – test at 20° §Usually non- Sens 81.8%, Spec 96.8% diagnostic

§Anterior drawer – test at 90° §Can help rule in or out injuries Sens 22 - 41%, Spec 97%*

§Pivot shift §Segond fracture – Sens 35 - 98.4%*, Spec 98%* avulsion over lateral Malanga GA, Nadler SF. Musculoskeletal Physical Examination, Mosby, 2006 tibial plateau * - denotes under anesthesia MRI MRI

§Sens 94%, Spec 84% §Sens 94%, Spec 84% for ACL tear for ACL tear ACL tear signs ACL tear signs §Fibers not seen in §Lateral femoral corner continuity bone bruise on T2 §Edema on T2 films §May have meniscal §PCL – kinked or tear (Lateral > medial) Question mark sign

Initial Treatment ACL Tear Treatment Conservative Surgery §Referral to Orthopaedics/Sports Medicine §No reconstruction §Reconstruction §Consider bracing, crutches § §Depends on activity §Begin early Physical Therapy ‒ Hamstring strengthening demands §Analgesia usually NSAIDs ‒ Proprioceptive training • Reconstruction allows better return to sports

§ACL bracing • Reduce chance of controversial symptomatic meniscal tear §Patient should be • Less giving way symptoms asymptomatic with §Recovery ~ 6-9 months ADL’s

Shea KG, et al. AAOS evidence based review, J Bone Joint Surg Am, 2015 Meniscus Tear What is True About Meniscal Tears?

Mechanism Symptoms 1. An MRI is the best test to diagnose the Meniscus tear §Occurs after twisting §Catching 2. The lateral meniscus is most commonly torn vs the injury or deep medial meniscus §Medial or lateral knee 3. Patients with a symptomatic meniscus tear are better §Patient may not recall pain off getting arthroscopy vs non-op treatment specific injury §Usually posterior 4. Patients can expect full recovery after meniscus aspects of joint line surgery §Swelling

Special Tests: Meniscus Modified McMurray Testing

Fowler PJ, Lubliner JA. Arthroscopy 1989; 5(3): 184-186.

Test Sensitivity Specificity §Flex hip to 90 degrees

Joint line tender 85.5% 29.4% §Flex knee

Hyperflexion 50% 68.2% §Internally or externally rotate lower leg with Extension block 84.7% 43.75% rotation of knee

McMurray Classic 28.75% 95.3% §Fully flex the knee with (Med Thud) rotations McMurray Classic (Lat 50% 29% pain) Appley (Comp/Dist) 16% / 5%

Courtesy of Keegan Duchicella MD Modified McMurray Testing X-ray

§Flex hip to 90 degrees §Flex knee §May show joint space narrowing and early §Internally or externally changes rotate lower leg with rotation of knee §Fully flex the knee with §Rule out loose bodies rotations

Courtesy of Keegan Duchicella MD

MRI Arthroscopy Benefit?

§An RCT showed that physical therapy vs arthrosopic partial meniscectomy had similar §MRI for specific exam outcomes at 6 months §30% of the patients who were assigned to §Look for fluid (linear physical therapy alone, underwent surgery within bright signal on T2) 6 months. into the meniscus

§ Katz JN et al. N Engl J Med. 2013

§ Sihvonen R et al; N Engl J Med. 2013 Exercise as Good as Arthroscopy? Meniscal Tear Treatment

§RCT found that patients with degenerative Conservative Surgery meniscus tears but no signs of arthritis on imaging treated conservatively with supervised §Often if degenerative §Operate if internal tear in older patient derangement exercise therapy had similar outcomes to those symptoms treated with arthroscopy with 2 year follow up. §Similar treatment to mild knee osteoarthritis §Meniscal repair if possible Kise NJ et al., BMJ, 2016 §Analgesia §Physical therapy ‒General Leg Strengthening

Medial Collateral Ligament (MCL) Medial Collateral Ligament (MCL) Injury Injury Mechanism Symptoms Physical Exam §Valgus stress to §Pain medially §Tender medially over MCL partially flexed knee (often proximally) §May feel unstable with §May lack ROM §Blow to lateral leg valgus “pseudolocking” §Valgus stress test – test at 20° Sens = 86 - 96 %

Malanga GA, Nadler SF. Musculoskeletal Physical Examination, Mosby, 2006 MRI MCL Treatment

Conservative Surgery §X-ray non-diagnostic §Analgesia §Rarely needs surgery (rarely avulsion) §Protected motion §MRI not usually +/- hinged brace necessary +/- crutches §Rule out meniscal tear §Early physical therapy

Patellofemoral Pain PFP Syndrome

§Excessive Symptoms §Tender over facets of compressive forces patella §Anterior over articulating §Apprehension sign §Worse with bending surfaces of PFP joint suggests possible (5x body wt), stairs (3x body wt) instability Mechanism §Crepitus under §Too loose/hypermobile kneecap §X-rays may show §Too tight – XS §May sublux if loose lateral deviation or tilt pressure Treatment Options What’s Hip? Too Loose/Weak Surgical (RARE) §Strengthen quads (Vastus §Last resort Medialis Obliquus) §Lateral release §Correct alignment (+/-orthotics) §Patellar realignment §Support (McConnell Taping, Bracing) Too Tight §Stretch hamstring, quadriceps, hip flexor §Strengthen quads, hip abductors §Correct alignment (+/-orthotics)

Femoral Acetabular Impingement Anatomy – Bony (F.A.I.) §Cam effect §Protrusion of femoral head – “bump” §Orientation of the acetabulum – acetabular version §Increased stress on labrum Examination Posterior Hip Pain Supine - Hip Piriformis syndrome §Hip Internal and External 10% of population ROM have sciatic nerve §Labral Impingement and passing through the Stress tests piriformis Beaton et al. Anat Rec, 70, 1937. Muscle vs sciatica

“FABER” Test MR Arthrogram

§For stressing anterior Enhanced sensitivity labrum 90% §Positive in 15/17 Slightly higher false §Also SI joint positive 20% Offers advantage of diagnostic injection of anaesthetic Anterior Hip Pain Intra-articular FAI Anterior Hip Pain Intra-articular Cam procedure FAI Labral repair or debridement Microfracture chondroplasty Osteoplasty Pincer procedure

Complications: adhesions, Acetabular resection fractures and AVN Labral reattachment

Shoulder Impingement Syndrome Shoulder Pain Differential Diagnosis

Mechanism Symptoms §Rotator cuff tendinopathy §Impingement under §Pain with §Rotator cuff tears acromion with flexion • Overhead activities §SLAP Lesion and internal rotation of §Calcific tendinopathy the shoulder • Sleep (Internal rotation) • Putting on a jacket §“Frozen” shoulder (adhesive capsulitis) §Rotator cuff, §Acromioclavicular joint problems subacromial bursa and biceps §Scapular weakness §Cervical radiculopathy What is True About Rotator Cuff Tears? Shoulder Impingement Syndrome

1. An MRI is the best test to diagnose rotator cuff LOOK tears §May have posterior 2. The supraspinatus tendon is the most shoulder atrophy if chronic commonly torn or RC tear §Poor posture 3. All patients with a are better off getting reconstruction vs non-op treatment FEEL §Tender over anterolateral 4. Patients can expect full recovery after rotator shoulder structures cuff repair MOVE §May lack full active ROM

Shoulder Impingement Syndrome MOVE

LOOK §May have posterior shoulder atrophy if chronic or RC tear §Poor posture FEEL §Tender over anterolateral shoulder structures MOVE §May lack full active ROM Painful Arc 60 - 120° Flexion and External rotation MOVE Rotator Cuff strength testing

Supraspinatus 30° §Empty can §Thumbs down abducted to 30º §Horizontally adduct to 30º For tendonitis Sens = 77 % Spec = 38 % For tears, Sens = 19 % External rotation Internal rotation Spec = 100 % Naredo et al. Ann Rheum Dis, 2002; 61: 132-136.

Rotator Cuff strength testing Rotator Cuff strength testing

Infraspinatus/teres minor - Subscapularis – Internal External rotation rotation / Lift-off test §Keep at 90º §Patte’s test at 90º For lesions, shoulder abduction Sens = 50 % For tendonitis, Spec = 84 % Sens = 57 % For tears, Spec = 71 % Sens = 50 % For tears, Spec = 95 % Sens = 36 % Spec = 95 %

Naredo et al. Ann Rheum Dis, 2002; 61: Naredo et al. Ann Rheum Dis, 2002; 61: 132-136. 132-136. Impingement Signs Impingement Signs

Hawkin’s test Neer §Flex shoulder to 90º §Passive full flexion §Flex to 90º §Positive is reproduction §Internally rotate of shoulder pain §Positive - reproduce shoulder pain Sens = 83 % Sens = 88 % Spec = 51 % Spec = 43 % PPV = 40 % PPV = 38 % NPV = 89 % NPV = 90 % MacDonald et al. J Shoulder Elbow Surg, 2000; 9: 299-301. MacDonald et al. J Shoulder Elbow Surg, 2000; 9: 299-301.

Impingement Signs X-ray AP Scapula

§Spurling’s test for §Avulsion cervical radiculopathy §Calcific tendinosis Sens = 64% §Enthesopathy (traction Spec = 95% spurs) PPV = 58% §Alignment NPV = 96% X-ray AC Joint view X-ray Lateral Scapula

§Osteoarthritis §Mercedes sign – humeral head should §Osteolysis be centered in glenoid

§Can check for “hooked” acromion

X-ray Lateral Scapula X-ray Axillary View

§Position §Posterior dislocation

Normal Large acromial spur Ultrasound MRI

§MRI not needed for conservative treatment §Dynamic test §Use it to rule out §Operator dependent significant pathology §Areas of tendinosis How good for full hypoechoic thickness tears? §Tears §69 to 100 percent sensitive §88 to 100 percent specific

Rotator Cuff Tears Rotator Cuff Treatment

Conservative Surgery §Education §If patient fails conservative treatment for > 6-12 §Modify Activities months §Alter Biomechanics / §If rotator cuff tear > 1 cm Decrease tendon load §Ice/NSAIDs (no evidence) §Subacromial §Eccentric exercise decompression programs +/- bursectomy §Steroid injection +/- rotator cuff repair Tear • slightly better than placebo Adhesive Capsulitis Frozen Shoulder “Frozen Shoulder” §Women greater than §Gradual loss of range of men (70%) motion §Age > 40 years §May have had initial trauma §Affects 2-5 % of §Pain at the extremes of population motion §20-30% develop symptoms in opposite §May have history of shoulder diabetes, hypothyroidism, rheumatoid arthritis, now Breast Cancer Tx

Diagnosis Natural History

§Limited range of §0-3 months “gradual onset” - painful motion (usually lose §2-9 months “ freezing” external rotation, abduction and flexion) §4-12 months “ frozen” §5-26 months “thawing” §Investigations (X-ray, Ultrasound) usually §Usually self-limited negative Hannafin & Chiaia, Clin Orthop Rel Res, 2000 Treatment Steroid injection §Pain management (+/- sling) §Education and reassurance §RCT showed intraarticular steroid injection provided better pain relief in the first 8 weeks §Active home stretching program than NSAIDs. §However, no difference was seen in range of §Physiotherapy motion or pain after 12 weeks §Oral NSAIDs (or steroids) §Results similar to other non-controlled studies §Glenohumeral injection capsular distension Ranalletta M at al., Am J Sports Med, 2016 §Rarely needs surgery (examination under anesthesia or Arthroscopic release)

Treatment What is a Concussion? §Pain management (+/- sling) §Education and reassurance §Type of mild traumatic brain injury §Active home stretching program §Blow to head, neck, body à force to head. §Neurologic impairment within 48 hours of trauma. §Physiotherapy §Oral NSAIDs (or steroids) §Symptoms usually resolve in 1-2 weeks §Glenohumeral injection capsular spontaneously but in some cases can be distension prolonged. §Rarely needs surgery (examination under anesthesia §May or may not include loss of consciousness. or Arthroscopic release) Evaluation Concussion Symptoms

Physical

Cognitiv Sleep e

Emotional

Consensus statement on concussion in sport: the 4th International http://www.cdc.gov/ncipc/tbi/Facts_for_Physicians_booklet.pdf. Accessed Nov. 9, 2008. Conference on Concussion in Sport held in Zurich, November 2012. Br J

Postural Stability Concussion Treatment

§Cognitive rest §Physical rest § • Tylenol • Ibuprofen after first 72 hours §No driving §No Etoh Diagnostic Imaging NSAIDs for Headaches

Neuroimaging (CT, MRI) §No studies show that NSAIDs harmful §Most patients do not require imaging §Anectodally, Naproxen > Ibuprofen > Tylenol §Use when suspicion of intracerebral structural lesion §OK to Medicate if symptomatic and it helps exists: • prolonged loss of consciousness • focal neurologic deficit §70% adolescent patients treated in a headache clinic with chronic posttraumatic headaches • worsening symptoms met criteria for medication overuse headaches • Deterioration in conscious state §Be careful of overmedicating Halstead ME, Sports Health , 2016

Symptom Resolution after Sport Concussion Return to play activity examples

§50% recovered and returned to play in 1 week; 90% in 3 weeks (Collins et al. Neurosurgery, 2006.) Step Objective Activities 1 Recovery No activity §7-10 days avg. symptom resolution. 2 Increase heart rate Walking, swimming, or stationary bike. < 70% max (3rd International Conference on Concussion in Sport heart rate. No weights. (2008). Clin J Sport Med, 2009.) 3 Add movement Skating drills in hockey, running drills in soccer. No head impact activities. §High schoolers take longer to recover based on neuropsychological testing compared to college athletes. 4 Add coordination and More complex drills (passing). Can start weights. (Field et al, J Pediatr, 2003.) cognitive load 5 Restore confidence Full-contact practice and assess functional skills by coaching staff 6 Normal game play

Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013 Apr;47(5):250-8 Symptoms during return to play Keys to Managing Sports Concussion

§If symptomatic during a step of the return to play §Treatment is rest. protocol… §Gradual return to learn. • Stop activity §Gradual return to play. • Rest until symptoms resolve, at least 24 hours. §Note for school and sports each visit. • Resume return to play protocol at the step where §Monitor for repeat injury. athlete was last asymptomatic §No recommended protective gear §Association between concussion and dementia (causality not proven) §Treat each case individually. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013 Apr;47(5):250-8

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