Ten Sports Medicine “Facts” Primary Care Physicians Should Know Robert Kiningham, MD Associate Professor Department of Family Medicine Michigan Medicine Disclosure

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• Neither I, Robert Kiningham, nor any family member(s), have any relevant financial relationship to be discussed, directly or indirectly, referred to, or illustrated with or without recognition, within the presentation. Ten Sports Medicine “Facts”

• Degenerative meniscus • Lisfranc fracture-dislocations • Treatment of uncomplicated ankle sprains • Use of knee immobilization • Shoulder labral lesions over age 40 • Gluteus medius tendinopathy • Static stretching • High risk fractures • Impact of age on shoulder injuries • The athlete with COVID Degenerative Meniscal Tears Should Not Be Treated • Degenerative meniscal tears are common in symptomatic and asymptomatic adults • Arthroscopic surgery to “repair” degenerative meniscal tears are not effective and possibly increase the risk of OA progression • Do not order a knee MRI in adults with non-traumatic knee pain without a specific indication The Clinical Importance of Meniscal Tears Demonstrated by Magnetic Resonance Imaging in Osteoarthritis of the Knee*. Bhattacharyya, Timothy; Gale, Daniel; Dewire, Peter; Totterman, Saara; Gale, M; McLaughlin, Sara; Einhorn, Thomas; Felson, David; MD, MPH

Journal of Bone & Joint Surgery - American Volume. 85(1):4-9, January 2003.

Fig. 1 :. Frequency of medial meniscal tears according to the radiographic grade 17 of osteoarthritis. The correlation between the frequency of the tears and the radiographic grade was significant (p < 0.001, r = 0.26).

Copyright 2003 by The Journal of Bone and Joint Surgery, Incorporated. Published by Journal of Bone & Joint 2 Surgery, Inc. The Clinical Importance of Meniscal Tears Demonstrated by Magnetic Resonance Imaging in Osteoarthritis of the Knee*. Bhattacharyya, Timothy; Gale, Daniel; Dewire, Peter; Totterman, Saara; Gale, M; McLaughlin, Sara; Einhorn, Thomas; Felson, David; MD, MPH

Journal of Bone & Joint Surgery - American Volume. 85(1):4-9, January 2003.

TABLE I : Frequency of Medial Meniscal Tears in Patients with Symptomatic Osteoarthritis and in Asymptomatic Controls

Journal of Bone & Joint Surgery - American Volume. 85(1):4-9, January 2003.

TABLE II : WOMAC* and Visual Analog Scale Pain Scores of Patients with and without a Medial Meniscal Tear in the Subgroup of Patients with Symptomatic Osteoarthritis and a Low Radiographic Grade 17

Copyright 2003 by The Journal of Bone and Joint Surgery, Incorporated. Published by Journal of Bone & Joint 2 Surgery, Inc. Evaluate for Lisfranc Fracture-Dislocation with a Traumatic Midfoot Injury Lisfranc Fracture Dislocation

• Significant swelling of the midfoot • Plantar midfoot ecchymosis • Tenderness over tarsometatarsal joints • Pain with weight-bearing and foot motion

K Burroughs, C Reimer , K Fields. Lisfranc injury of the foot. Am Fam Physician 1998;58:121 Lisfranc Injury • Lisfranc ligament

Base of 2nd Medial Metatarsal Cuneiform Separation of the base of the 1st and 2nd metatarsals leads to forefoot instability

• Diastasis requires referral to orthopedics Lisfranc Injury

• Fleck Sign: Avulsion off base • of 2nd metatarsal

http://orthoinfo.aaos.org Lisfranc Injury

• Weight bearing/Stress views:  Diastasis = 2mm between 1st and 2nd metatarsal bases

http://orthoinfo.aaos.org/ Uncomplicated Ankle Sprains Should Be Treated with Early Mobilization Treatment of Ankle Sprains

• Early mobilization and functional ankle support are better than immobilization in the management of acute ankle sprains, especially grades I and II • Early weight bearing with support reduces symptoms • Sooner return to sport or work • Decreased ligamentous laxity • Grade III sprains: a short episode of immobilization (< 10 days) may decrease pain and swelling and improve functional outcome

Halabch F, Hassabi M. World J Orthop 2020;11: 534-538 Avoid Knee Immobilizers! (with few exceptions) Knee Immobilizer • Complete immobilization of the knee for an extended period is generally contraindicated because of the prolonged stiffness, muscle atrophy, and chronic pain • Knee immobilizer is recommended only in patellar dislocation or fracture, quadricep or patellar tendon rupture, MCL tendon rupture, ACL tear • Duration of immobilization and management of these conditions is variable • Should be seen by Sports Medicine or Ortho ASAP 16 Ignore GH Labral Lesions in Adults Over 40 SLAP Lesions in Patients > 40 • 55-73% of asymptomatic adults ages 45-60 with no h/o shoulder injury or surgery have superior labral tears on MRI • Regardless of age, sex, dominant shoulder, h/o physical work, h/o overhead sports participation for >1 year

• Age > 40 is an independent risk factor increased surgical complications and failure for SLAP repairs with an associated rotator cuf injury

Erickson J et al. Am J Sports Med 2014; 43:1274-82

Schwartzberg R et al. Orthop J Sports Med 2016: 4 (1) Gluteus Medius Tendinopathy is Common Greater Trochanteric Bursitis is Not • Traditionally lateral hip pain has been diagnosed as trochanteric bursitis but this has been challenged by imaging and histology • Non-inflammatory insertional tendinopathy of the gluteus medius and/or gluteus minimus is now considered the primary pathology underpinning lateral hip pain • Most common lower extremity tendinopathy • Common in women >40 • Pain is usually insidious and worsens over time • Related to changes in physical activity • Can occur acutely after strong contraction of abductors • Pain with single leg activities • Pain worse at night Gluteal Tendinopathy

• Gluteus medius (GMe) and minimus (GMi) are primary hip abductors • GMe is the main pelvic stabilizer during single-leg stance, preventing the contralateral pelvis from tilting downward. • Gluteal tendinopathy is the most prevalent of all lower limb tendinopathies • Gluteal tendinopathy incorporates what used to be called greater trochanteric bursitis, and is also at the root of IT band syndrome. Gluteal Tendinopathy

Grimaldi et al. Sports Med 2015;45:1107-19 Gluteus Medius/Minimus Tendinopathy

Karim Khan, Karim. Lateral hip pain-more likely gluetues medius tendinopathy than trochanteric burstis. 21 Nov, 10. http://blogs.bmj.com/ Gluteal Tendinopathy Clinical Presentation • Lateral hip pain of gradual onset • Often associated with changes in work load or physical activity, particularly running • Pain can progress to night pain (prohibiting sleeping on the affected side) • Single leg loading tasks – walking/running, standing on one leg to dress, climbing stairs/hills – are particularly painful • Stiffness with extending hip when getting out of a chair Gluteal Tendinopathy Physical Exam • Tenderness over greater trochanter • Trendelenburg variations (sustained single-leg stance tests) • Resisted hip abduction – best done with the hip adducted • Resisted external derotation test • Ober test • FABER (Patrick test) Resisted External Derotation Test

Lequesne et al. Arthritis Rheum 2008; 59:241-246 Consequences of Weak Hip Abduction • Iliac crest on stance side drops • Femur forced into internal rotation • Results in valgus stress at the knee • Tibia internally rotates to compensate • Foot also over-pronates to compensate • Result: lateral tracking/tilt of patella Trendelenburg Test Gluteal Tendinopathy Treatment • Hip abductor and flexor strengthening • Decreased peak hip adduction in running – increasing cadence • Corticosteroid injections • Bursitis alone is rare with trochanteric pain • Only temporarily relieves pain and does not treat underlying primary pathology • Positive responses initially (though in some studies still only 55%) • Drop to 41-55% at 3-4 months and no change after 12 months • May cause further tendon degeneration • Dry needling and PRP Static Stretching Does Not Reduce Injury Risk or Improve Performance in Runners Static Stretching Does Not Reduce Injury Risk or Improve Performance in Runners • Stretching either in the short or long term has no impact on injury risk in endurance runners • Static stretching will improve joint flexibility, but these improvements have not been associated with benefits in recovery, performance, or running economy • An active warm-up has been shown to improve performance • Impact on injury risk remains unclear

Alexander JLN, et al. Br J Sports Med 2020;54:1058-59 Check For High-Risk Fractures •Scaphoid fracture •Base of the 5th metatarsal •Tibia shaft stress fracture •Tensile femoral neck stress fracture FOOSH Injuries Scaphoid Fracture FOOSH Injuries Scaphoid Fracture • Tenderness in anatomic snuff box • Susceptible to AVN because of poor blood supply • X-rays may be initially negative • If tender, place in thumb spica splint and re-examine and x-ray in 7-14 days 5th Metatarsal Fracture

Strayer et al. Fractures of the proximal fifth metatarsal. Am Fam Physician. 1999 May 1;59(9):2516-2522. 5th Metatarsal Fractures

Avulsion Fracture: -- Weight bearing as tolerated -- Hard soled shoe -- Rarely, surgical repair for large, displaced, intra-articular fragments

Jones Fracture: -- Metaphyseal-diaphyseal junction -- Circulatory ‘watershed’ region at risk of nonunion -- Non-weight-bearing x 6-8 weeks Tibial Stress Fracture Femoral Neck Stress Fractures Femoral Head Tension Stress Fracture Shoulder Injuries: Importance of Age

The Athlete with COVID

•Risk of myocarditis •Decreased endurance •Long term effects?