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Sports Related Neuromuscular Disorders Anthony E. Chiodo, MD Lawrence W. Frank, MD Andrew H. Dubin, MD, MS Francis P. Lagattuta, MD 2008 COURSE G AANEM 55th Annual Meeting Providence, Rhode Island Copyright © September 2008 American Association of Neuromuscular & Electrodiagnostic Medicine 2621 Superior Drive NW Rochester, MN 55901 Printed by Johnson Printing Company, Inc. ii iii iii Sports Related Neuromuscular Disorders Faculty Anthony E. Chiodo, MD Andrew H. Dubin, MD,MS Associate Professor Associate Professor Department of Physical Medicine and Rehabilitation Albany Medical Center Hospital Director of Spinal Cord Injury Medicine Department of Physical Medicine and Rehabilitation University of Michigan Medical Center Albany, New York Ann Arbor, Michigan Dr. Dubin is currently an associate professor of physical medicine and After completing his medical school training in his home state at the rehabilitation at Albany Medical College. He received his medical degree University of Connecticut Health Center, Dr. Chiodo started his physi- from Albany Medical College, and completed his residency at Thomas atric career at the University of Michigan Hospital where he completed Jefferson University Hospital in Philadelphia. He is board certified by his residency and neuromuscular fellowship. He had a private prac- the American Board of Physical Medicine and Rehabilitation and the tice in Pediatric Rehabilitation at Methodist Hospital in Indianapolis American Board of Electrodiagnostic Medicine. His particular interests and was Medical Director of Physical Medicine and Rehabilitation in include the areas of spasticity and treatment of neuropathic pain. Farmington, New Mexico on the border of the Navajo reservation. Dr. Chiodo returned to the University of Michigan in 1998. His aca- demic areas of interest include anatomic localization in electromyography, Francis P. Lagattuta, MD lumbosacral plexopathy after pelvic trauma, and clinical electrodiagnostics. Director He is board certified in pain medicine and spinal cord injury, applying his LAGS Spine and Sportscare research emphasis in electrodiagnostics to those areas of specialty as well. Santa Maria, California He has continued his work in the care for the disabled in underserved areas that he started in New Mexico by working on sustainable medical Dr. Lagattuta is one of the pioneer pain interventionalists. He is board rehabilitation program development in Ghana, West Africa. certified in pain medicine, physical medicine and rehabilitation, and elec- trodiagnostic medicine. He originally had a practice in Chicago and was involved in sports medicine serving as the team doctor for the Naperville Lawrence W. Frank, MD and Wheaton high schools, and the Chicago Bulls. He now has his offices in Santa Barbara, Santa Maria, Atascadero, and Lompoc, California with a Assistant Professor surgical center in Santa Maria. He is the Current Procedural Terminology Department of Physical Medicine and Rehabilitation (CPT) representative for the American Academy of Physical Medicine and Department of Neurological Surgery Rehabilitation (AAPMR) from 2004 to present. He was the CPT repre- Rush Medical College sentative for the North American Spine Society (NASS) from 2000-2004. Chicago, Illinois Dr. Lagattuta has been a board member for the American Association Dr. Frank received his BS in Electrical Engineering from the University of Neuromuscular and Electrodiagnostic Medicine (AANEM) and the of Illinois in Urbana-Champaign and his medical degree from the Physiatrist Association of Spine, Sports Medicine, and Occupational University of Illinois at Chicago. He completed his residency in Physical Medicine in addition to serving on multiple committees for AANEM, Medicine and Rehabilitation at the Rehabilitation Institute of Chicago AAPMR, and NASS. He has written numerous articles and given many at Northwestern University followed by a fellowship in Spine and Sports national presentations. Medicine at Illinois Spine and SportsCare in Bloomingdale, IL. Dr. Frank is the founder and medical director of Spine & Sports Physiatrists in Elmhurst, IL. He has extensive sports medicine experience including team physician positions with high school athletic teams, the Chicago Fire Professional Soccer Club and the FIFA Women’s World Cup. He is a guest examiner for the American Board of Physical Medicine and Rehabilitation and the American Board of Electrodiagnostic Medicine. He is Past- President of the Illinois Society of Physical Medicine and Rehabilitation and has served as a board member of the Physiatric Association of Spine Sports and Occupational Rehabilitation. Authors had nothing to disclose. Course Chair: Anthony E. Chiodo, MD The ideas and opinions expressed in this publication are solely those of the specific authors and do not necessarily represent those of the AANEM. iv Sports Related Neuromuscular Disorders Please be aware that some of the medical devices or pharmaceuticals discussed in this handout may not be cleared by the FDA or cleared by the FDA for the specific use described by the authors and are “off-label” (i.e., a use not described on the product’s label). “Off-label” devices or pharmaceuticals may be used if, in the judgement of the treating physician, such use is medically indi- cated to treat a patient’s condition. Information regarding the FDA clearance status of a particular device or pharmaceutical may be obtained by reading the product’s package labeling, by contacting a sales representative or legal counsel of the manufacturer of the device or pharmaceutical, or by contacting the FDA at 1-800-638-2041. v Sports Related Neuromuscular Disorders Contents Faculty iii Objectives v Course Committee vi Sciatica in Athletes 1 Anthony E. Chiodo, MD Stingers and Burners 5 Lawrence W. Frank, MD Upper Extremity Mononeuropathies 9 Andrew H. Dubin, MD, MS Mononeuropathies of the Lower Extremities in Sports 15 Francis P. Lagattuta, MD CME Activity and Faculty Evaluation 25 O BJECTIVES —After attending this session, participants will be able to (1) list the diagnoses associated with the presentation of sciatica in athletes, (2) distinguish on-the-field clinical characteristics of cervical radiculopathy versus brachial plexopathy, (3) understand return-to-play criteria for burner - stinger injuries, (4) formulate a differential diagnosis for nerve injuries from sports, (5) formulate an electrodiagnostic test to determine the exact nerve injury, and (6) prescribe a treatment program for the specific nerve problem. P REREQUISITE —This course is designed as an educational opportunity for physicians. A CCREDIT A TI O N ST A TEMENT —The AANEM is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education (CME) for physicians. CME CREDIT —The AANEM is accredited by the ACCME to provide continuing medical education (CME) for physicians. The AANEM designates this educational activity for a maximum of 2 AMA PRA Category 1 Credit(s) TM. Each physician should only claim credit commensurate with the extent of their participation in the activity. This event is an Accredited Group Learning Activity as defined by the Maintenance of Certification Program of The Royal College of Physicians and Surgeons of Canada. CME for this activity is available 9/08 - 9/11. vi 2007-2008 AANEM COURSE COMMITTEE Anthony E. Chiodo, MD, Chair Ann Arbor, Michigan Shawn J. Bird, MD Erick A. Grana, MD Simon Zimnowodzki, MD Philadelphia, Pennsylvania Tampa, Florida Chicago, Illinois Kevin B. Boylan, MD Thomas Y.C. Pang, MD Sasa Zivkovic, MD Jacksonville, Florida Chicago, Illinois Pittsburgh, Pennsylvania Gary L. Branch, DO David Bryan Shuster, MD Owosso, Michigan Dayton, Ohio 2007-2008 AANEM PRESIDENT Peter D. Donofrio, MD Nashville, Tennessee 1 Sciatica in Athletes Anthony E. Chiodo, MD Associate Professor Department of Physical Medicine and Rehabilitation Director of Spinal Cord Injury Medicine University of Michigan Medical Center Ann Arbor, Michigan INTRODUCTION important role that the disc and vertebral body play in the stabil- ity of the trunk in all activities that put it at risk. Under normal Lumbar spine dysfunction among athletes presents a particular conditions, the intervertebral disc carries 80% to 85% of the challenge to the treating physician because these patients have a axial load, while the two facet joints collectively carry the remain- high-activity level and want a swift return to their sport. Traditional ing 15% to 20%. With forward flexion, the disc is placed at the treatment plans that include activity modification must consider load with the resultant torque created by the head and by objects the need for continued physical conditioning to sustain the athlete’s carried increasing intradiscal pressures as high as 7 times more conditioning results from months of previous sport-specific exercise. than in static standing. With spine extension, there is an increased Although the long-term outcome of treatment is important, a quick percentage of weight carried by the facet joints. Degeneration return to the athlete’s activity is critical. A quick return may or may of the discs or of the facet joints can result in changes in these not be the fastest path to the completion of treatment; shorter term percentages due to mechanical malalignment, pain avoidance, treatments that will return the athlete to activity and keep them going or instability.39 through the season may be preferred by the athlete to a definitive treatment plan that might require more lengthy activity
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