SPORTS MEDICINE AND PHYSICAL FITNESS

Board Review 2/1/2013

Test QuestionWe are going to do Adolescent for the

next two board reviews….yay! Who likes adolescents?

A. I do! They are amazing!B. A 17 yr old female with abdominal pain

is my worst nightmare

EVALUATION FOR SPORTS PARTICIPATION

Introduction Sports participation is increasing. The benefit of playing sports is multi-factorial

Children involved in sports learn leadership and cooperative skills.

Organized sports can be a source of needed physical activity.

Pre-participation evaluation (PPE) Utility has been questioned, as it likely does little

to prevent morbidity and mortality in screened athletes

However…the AAP endorses these exams because it allows for establishment of a medical home and more effective well child care!

Pre-Participation Examination The PPE is required before practice and play by most sporting organizations Typically required every 1-2 years (for middle

and high school athletes) To shield the organization from liability To ensure that the athlete can participate safely

in sports Should be scheduled at least 6 weeks in

advance to allow time for appropriate follow-up if warranted

Various formats Office-based with the pediatrician Station-based at the school

Medical History Similar to typical history obtained at WCC

PMH, PSH, social history, developmental history

ALWAYS important to get the parent’s input, as there are often inconsistencies

Medical History Medications: Review all medications and

determine if any are banned substances, which may require a therapeutic use exemption (TUE)

Musculoskeletal: current injuries; any history of injury requiring evaluation, casting, bracing, surgery, or missed practice/play >90% sensitive at identifying musculoskeletal

injuries Pulmonary: Baseline lung disease, exercise

induced asthma, vocal cord dysfunction, etc. Neurologic: any history of concussion,

“stingers”, cervical cord damage/symptoms

Medical History Dermatologic: ask about skin wounds/infections

and ensure proper resolution before return to play (especially contact)

Ophthalmologic: Patients may require appropriate lenses for a specific sport (ie. contacts only for wrestling, boxing, and rugby). If best corrected vision is worse than 20/40 in one

eye (“functionally one-eyed”), must wear approved eyewear!

ID: Mononucleosis precludes from sports for 3-4 weeks, HIV/hepatitis or other blood-borne illness does not preclude…universal precautions

Heat illness: past diagnosis increases future risks

Medical History Genitourinary:

Few components of the GU history will disqualify an athlete or require modified participation. Solitary or horseshoe kidney require individual

assessment for contact or collision sports Protective equipment Risks v. benefit

Pain in inguinal canal region suggesting hernia Female athlete triad:

Disordered eating Amenorrhea Osteoporosis

Psychological: Eating disorders (especially in weight restricted sports and aesthetic sports), depression/anxiety, ADHD (meds)…

Question #1Which of the following would NOT require

referral to a cardiologist before clearing your patient for sports participation?

A. Known congenital heart diseaseB. Marfan SyndromeC. A 2/6 systolic vibratory/musical quality

murmur at the left lower sternal borderD. Family history of prolonged QT

syndromeE. Cardiomyopathy

Cardiovascular History Component of the

PPE that receives the most attention

The AHA recommends particular components of the cardiovascular history and exam prior to sports participation.

Cardiovascular History Red flags that need investigation by

cardiology! Known congenital heart disease Channelopathies (long QT or Brugada

Syndrome) History of myocarditis or coronary anomalies (ie.

Kawasaki disease) Family history of sudden cardiac death Marfan syndrome Cardiomyopathy

Must be worked up by PCP or Cardiology… Syncope, near-syncope Chest pain, palpitations, excessive SOB or

fatigue with exertion

Cardiovascular History ALL patients with syncope should have

an EKG, with further testing as indicated. Post-exertional syncope

Common Benign condition that should be differentiated

from exercise-associated collapse Exercise-associated collapse

Occurs DURING exertion An ominous sign of hemodynamically

significant cardiovascular disease or ventricular tachyarrhythmias

Physical Exam Vital Signs: often different than non-athlete…

low HR, wide pulse pressure, low resting RR BP should be normal, and any elevation requires

evaluation and treatment Mild-moderate HTN (>95%): encourage sports Severe HTN (>5mmHg over the 99%): disqualify

from sports with high static demand, heavy weights and powerlifting

HEENT: Visual acuity (special protection if not better than 20/40), auricular cartilage, nasal septum…ENT referral if damaged

Neurologic: Any past history should prompt a thorough exam

Musculoskeletal: the PE adds little diagnostic value to the history, cursory evaluate strength and ROM if no complaints

Physical Exam Genitourinary: not necessary in female unless

complaints; for males… Bilateral testicles? If only one testicle…protective

cup. Inguinal hernia exam in patients history of groin

pain. Cardiovascular:

Any cardiac abnormality that is not clearly benign should be FULLY evaluated by a cardiologist before sports participation.

Screening echo and EKG are NOT part of the PPE.

SPECIAL CIRCUMSTANCES:

RESTRICTION & DISQUALIFICATION

Question #2As the sports physician for the local high

school football team, you are asked to lecture some coaches on safe sports participation. Which of these do you counsel them is an ABSOLUTE contraindication to playing football?

A. Seizure disorderB. Diabetes mellitisC. HIVD. Febrile illnessE. Sickle cell disease

Sports Restriction Any condition that cannot be well-controlled and

puts the athlete at risk of significant injury or death OR endangers the health of teammates or competitors requires further evaluation and disqualification from a sport.

The PCP’s first responsibility is to ensure the safety of the patient

BUT…the physical and psychological benefits of exercise and sports participation should also factor into the decision to restrict sports participation for a patient. IF a physician disqualifies an athlete from one sport,

he/she should attempt to direct them to another sport!

Acute Febrile Illness ABSOLUTE contraindication to both sports

practice and competition!

Puts athlete at risk Acute heat illness Reduced maximal exercise capacity Hypotension

Decreased PVR Possible dehydration

Question #3You are seeing a 5 yo male with Down

Syndrome. He is participating in the Special Olympics in a few months. Which test do you want to order before clearing him for participation?

A. EchocardiogramB. EKGC. Pulmonary function testsD. MRI of the neckE. Cervical spine X-rays

Down Syndrome Children with Down Syndrome often require

interdisciplinary care to maximize their health outcomes and quality of life.

Cervical Spine Instability Primarily atlantoaxial but also occipitoatlantal Reported in up to 30% of patients MUST get radiographic evaluation of the

cervical spine before sports participation! NO collision sports, even if normal films Abnormal x-rays: disqualify from “neck

stressing” sports (diving, butterfly stroke, gymnastics, high jump, soccer)

Other medical conditions should be evaluated, too

Seizure Disorder Well-controlled seizures

Should NOT be disqualified from sports participation.

Think of “return to driving” laws and necessary seizure-free interval!

Poorly controlled seizures Individual assessments should be made to

determine suitability for contact/collision sports AVOID

Archery, riflery Power lifting, weight lifting, weight training Swimming Sports involving heights (parachuting, hang-

gliding)

Type I Diabetes Patients are allowed to participate in sports

without restriction. Monitoring and treatment often becomes

more complex with the varying demands of organized sports! Careful evaluation and monitoring are

essential Blood glucose

Check more frequently Q30 minutes during continuous exercise, 15

minutes after completion, and at bedtime Diet Insulin dose and type Hydration status

Question #4Which of the following patients with a

known medical condition is NOT disqualified from sports participation?

A. CardiomyopathyB. Hypermobility Ehlers-Danlos syndromeC. Acute Kawasaki diseaseD. Severe aortic stenosisE. Severe aortic regurgitation

Cardiovascular Disease Conditions that DISQUALIFY from sports

participation Pulmonary vascular disease with cyanosis or

significant right-to-left shunt Severe pulmonary stenosis (untreated) Severe aortic stenosis or regurgitation (untreated) Severe Mitral stenosis or regurgitation (untreated) ANY cardiomyopathy Vascular Ehlers-Danlos syndrome Coronary anomalies (especially anomalous origin) Catecholaminergic polymorphic V-tach Acute pericarditis, myocarditis, or Kawasaki

disease

**ANY CV disease should be thoroughly evaluated and treated by a pediatric cardiologist to ensure safe participation in sports!

Injury Prevention NO contact sports

Splenomegaly Mono or mono-like illness: risk of splenic rupture

Any athlete with this illness should be disqualified from sports with risk of abdominal trauma for 3-4 weeks after symptoms start

Acute hepatomegaly Contagious skin lesions (until treated and

resolved) Single organs

Kidney (single or horseshoe) Avoid high contact sports Individual assessment required for other

contact/collision sports (weigh risk v. benefit) Others

Appropriate protective gear.

HEAT ILLNESS

Mechanism Caused by an inability to maintain a normal

body temperature Excess heat production Decreased heat transfer to the environment Normal heat transfer mechanisms are

overwhelmed and central thermoregulatory control is ineffective

Heat stroke = MEDICAL EMERGENCY Arises when cellular injury is caused by the

excess body temperature Core temp > 105.8 (41C) for more than a

short time = thermal injury Proteins denatured Injured cells undergo apoptosis or necrosis

Question #5Which of the following clinical findings

typically distinguishes heat exhaustion from heat stroke?

A. Severe neurologic dysfunctionB. An elevated core temperatureC. Signs of dehydrationD. Nausea and vomitingE. Confusion

Forms of Heat IllnessHeat stress Discomfort and physiologic strain from exposure to a hot

environment Core temperature remains within the normal range Decreased exercise performance but usually no other

symptomsHeat Exhaustion Elevation of core body temperature (100.4-104) after

strenuous exercise OR exposure to high temperatures Mild dehydration, +/- sodium abnormalities Intense discomfort, confusion, thirst, nausea, and vomiting NO severe neurologic symptoms

Heat Stroke Elevation of core body temperature >104 Neurologic dysfunction Symptoms: dry skin, dizziness, confusion, syncope

Heat StrokeThe incidence of heat stroke is greater during periods of unusually high temperatures.

This is compounded for young children and infants because they have less tolerance to exercise than adults when air temperature is greater than body temperature!

Risk factors Prolonged exertion in a warm, humid environment Dehydration Infants and young children: over-bundling or left

in cars during the summer Disabled patients and elderly (can’t remove

themselves from environment

EvaluationShould be considered in any patient with significant core temperature elevation (>104) and mental status changes.

Complications of Heat StrokeMulti-system illness Elevated temperature CNS dysfunction: delirium, coma, seizures

Severe damage not observed until the rectal temp > 105.8

Hypotensive shock Initially due to peripheral vasodilation Later because of cardiac damage

GI: swelling, hemorrhage, and hepatic damage Renal failure

Prerenal azotemia with BUN:Cr ratio >20 Hematologic abnormalities: anemia,

thrombocytopenia, coagulopathy

Question #6What is the MOST important FIRST step in

treating your patient with heat illness?A. Volume resuscitation with IVF bolusesB. Immersion in ice water to drop

temperatureC. Removal from heat and cessation of

exerciseD. FFP and plateletsE. Immediate intubation even if the

patient is breathing adequately initially

Treatment

Phase 1: Immediate removal from the heat source, cessation of exercise, and hydration

Phase 2: Cool the patient to < 104 as rapidly as possible to prevent ongoing injury Immersion in ice water may be most

effective If not practical…simple evaporative cooling

May be as effective as some active cooling measures

Less uncomfortable for the patientPhase 3: Supportive Care

Supportive CareShock

IV rehydration for all heat stroke and MOST heat exhaustion (can use chilled IVF if temp > 104)

VaspressorsHematologic and coagulation abnormalities

Monitor CBCs and coags FFP and platelets if bleeding occurs

Neuro changes Anti-seizure meds: phenytoin often used Close Na control to decrease risk of cerebral edema

Respiratory failure is usually central, and minimal vent support is usually required

Hepatic damage typically resolves spontaneously; liver transplant is a last resort

Question #7What is the most likely long-term outcome

that you will see in a patient who has suffered from a moderate-to-severe heat stroke?

A. Chronic renal failureB. Hepatic dysfunction requiring liver

transplantC. Persistent anemia and thrombocytopeniaD. DeathE. Behavioral changes and poor coordination

OutcomeMild heat stroke: generally recover uneventfully with normal neurologic function when tested several months later

Moderate-to-severe heat stroke: Risk of sequelae is higher, especially if core temp >

107.6 Generally recover from hepatic and renal injury Neurologic injury is often permanent

Behavior changes Impaired memory Ataxic gait, poor coordination Dysarthria, decreased visual acuity

Up to 1/3 with spasticity and pan-cerebellar syndrome

Mortality for severe cases = 10%

PreventionRisk assessment with the heat index chart Recognizing signs of heat illness…excessive fatigue, confusion, muscle cramps at onset

Proper hydration during ALL practices and competition!! Significant amounts of sodium are lost in sweat, so

electrolyte replacement is essential Encourage liquids containing electrolyte solutions

(sports drinks) Adults: 500mL within 2h prior to exercise, 250mL

q20 minutes during exerciseAcclimation to warm conditions 3-4 days before competing

Light colored, loose fitting clothes

EXTRA

Weight in SportsSome sports place an emphasis on weight and body mass…either a lean image or a more muscular appearance.

Youth often resort to unhealthy, pathologic dieting and exercise practices, supplement use, and drug ingestion to reach a desired weight.

Healthy weight changes Weight loss: should not exceed 1.5% of total

body weight/week or 1-2 pounds/week Weight loss beyond these guidelines causes

breakdown of muscle, resulting in muscle weakness

Appropriate diet for most athletes = minimum of 2000 kcal/day

Sports Training Preventative conditioning should include both

aerobic conditioning and strength training. The most significant risks to athletes involve

strength training, but this can be minimized High repetition with low resistance

1st teach proper technique with no weight Add small weight increments as strength increases 20-30 minute sessions, 2-3 days per week

Power lifting programs should NOT be undertaken by preadolescents (middle school) because of the risk of injury…immature skeletal system Muscle strain Epiphyseal injury to the wrist Apophyseal injury

Hematomas Quadriceps

Trauma can be associated with a significant amount of blood lost into a deep hematoma of the thigh

Rarely enough to cause hypovolemia or VS changes

Complications Myositis ossificans (up to 9%)

Bone formation in injured muscle 3-4 weeks later

Firm, nontender swelling Peripheral calcification on plain radiograph Typically resolves over months; may rarely

require surgical excision

Treat any hematoma with ice, compression, NSAIDs, and early mobilization!

Managing Sports Injuries in the Pediatric Office

Head Injury Closed head injury is a common medical

problem in young athletes Yet majority of concussive episodes are not

reported Incidence is unknown but roughly 300,000

cases per year in the US High and medium-contact sports carry a

greater risk for head injury compared to noncontact sports

Question #8Which of the following is NOT characteristic of a

concussion?A. Impairment of neurologic function resolves

with aggressive cognitive reconditioningB. Pathophysiology involves traumatic

biomechanical forcesC. Neuropathologic changes are more

indicative of functional derangement rather than structural injury

D. Neuroimaging typically is grossly normalE. Symptoms can include confusion, amnesia,

and insomnia

Concussion Significant head injury

which causes an alteration in consciousness Confusion, amnesia, visual

or hearing impairment, irritability and mood changes, difficulties with balance, headache, lethargy, insomnia, memory impairment, n/v

Neurologic impairment is rapid onset, short-lived, and tends to resolve spontaneously

Neuroimaging is grossly normal

Multiple tools available to grade the severity

Question #9Which of the following statements regarding the

understanding and management of a head injury is FALSE?

A. A sequential progression of activity is a critical aspect of return to play criteria after a concussion

B. A history of previous concussion is irrelevant to the management of a current concussion

C. Postconcussive syndrome can happen even after a minor concussion

D. Patients with persistent signs and symptoms of concussion should be referred for neuropsychological assessment

E. Second impact syndrome is associated with a mortality rate of 70-80%

Concussion Complications For patients with persistent signs and

symptoms or for symptoms that recur with exertion Neuropsychological assessment

Postconcussive Syndrome Residual symptoms from a concussion Can exists after ANY grade of concussion

Second Impact Syndrome A second closed head injury while the patient

is still symptomatic from the first injury Rapid and progressive brain injury 70-80% mortality

Return to Play… When player’s symptoms have resolved

AND when he/she has demonstrated the ability to progress stepwise through several levels of activity without recurrence of symptoms

Advancement between steps ONLY if there are NO symptoms If symptoms do recur, the athlete should rest for

24-48hrs before trying to progress again Each regimen should be individualized to

each athlete and progress monitored by those with appropriate training

Complete rest; mental and physical

Light (low-intensity) aerobic exercise such as walking; NO resistance

Activity specific to the sport such as running or skating; may add minimal resistance

Training drills without contact, followed by mental status testing

Full-contact training after clearance by medical personnel

Question #10Which of the following sports

accounts for the greatest percentage of cervical spine injuries in the youth in United States?

A. Synchronized divingB. WrestlingC. SoccerD. BoxingE. Football

Neck Injury C-spine injuries occur most often in medium

and high-contact sports Typically occur through a ‘head-first’ mechanism In the US: football poses greatest risk for injury

50% of ALL c-spine injuries **don’t forget about water sports!!**

Preparation: On-site emergency personnel (or ability to access

EMS) Discussion with a certified athletic trainer Immobilization equipment available Understanding of the steps required to manage an

acute cervical spine injury

Neck Injury Initial Management

ABCs!! Remove face mask to assess airway Do NOT remove helmet or shoulder pads

These help ensure neutral alignment of the c-spine

If found prone, log roll to supine position One person at head; two at body Head turns at same speed as the body

Improper handling of a neck injury increases the risk for neurologic deficiency**

Neck Injury In all patients with suspected c-spine

injury Keep neck immobilized until bony injury can

be ruled out Xrays of the c-spine: 5 views

AP Lateral Flexion Extension Odontoid

Neck Injury Return to play criteria after suspected c-

spine injury with NORMAL radiographic findings: No pain with motion of the cervical spine No pain with palpation of the cervical spine No report of radicular symptoms emanating

from the cervical spine Results of all neurologic examinations and

associated tests are normal **Must be evaluated by a physician prior to

return to play**

Ankle Injury First step in

diagnosis: an accurate history Most common

mechanism is inversion Eversion injury

associated with more severe injury

Most common reason for ankle injury is incomplete healing of previous injury

Question #11Which of the following injuries is the

most likely in an athlete with open growth plates who has inverted their ankle during play?

A. Fracture of the 5th metatarsalB. Rupture of the achilles tendonC. Sprain of the posterior talofibular

ligamentD. Fracture of the fibular physisE. Dislocation of the ankle

Ankle Injury Physical exam:

Observation and inspection Watching the patient walk can help

differentiate between a ligament injury or a more serious fracture

Ankle exam Inversion mechanism: injury to lateral portion

of foot and ankle Anterior and posterior talofibular ligaments Proximal 5th metatarsal

Ankle Injury Inverted ankle injury in a patient with OPEN

growth plates Fracture of the fibular physis (growth plate)**

MOST LIKELY injury in this type of patient MORE common than a sprain in this age group!!

On exam: pain on palpation of lateral ankle

X-rays must be obtained for any suspected bony injury Ankle: 3 views Foot: 3views

if 5th metatarsal fracture is suspected

Question #12Which of the following is NOT part of the

management for uncomplicated ankle injury (no bone specific tenderness; normal xrays)

A. Rest, Ice, Compression, and Elevation for the first 5-7 days

B. A process of ankle mobilization over time that begins with range of motion movements of the ankle

C. Progressive strengthening of the ankle using a device such as an elastic band

D. Referral to physical therapy if the pain persists for more than 2-3 weeks

E. Allowing complete healing of the ankle injury prior to returning to play

Ankle Injury Management of uncomplicated ankle

injury(No bone-specific tenderness)

RICE (rest, ice, compression, elevation) for the first 48hrs

Progressive ankle mobilization Start with ankle movement

Trace alphabet with first toe Strengthening exercises

Elastic band to flex against resistance 3 sets of 15 repetitions; daily for 6 weeks

If ankle injury persists after a few weeks refer to physical therapy

Return to play after ankle injury:

Answer must be NO to all questions: Is there any limitation of normal athletic

function with the injury? Is there any ongoing swelling or loss of

motion in the affected joint? Has the proper preventative strategy been

employed? i.e. Ankle strengthening for ankle injuries

Applies to any injury to shoulder, knee, stress fracture, shin splints, as well

Return to play… Free of pain and swelling before and

after exercise Full range of motion, flexibility, and

stability 95% of normal strength Recommend a stepwise return to

competition Gradual increases in duration and intensity

of practice

Knee Injuries

Pediatric and adolescent athletes who have sustained knee injuries often present initially to their primary care doctor

Damage to the bone, ligaments, or cartilaginous structures may occur, depending on the mechanism of injury

Question #13Which of the following clinical tests would

be most appropriate in diagnosing an MCL tear?

A. Inspection and range of motionB. Lachman testC. Anterior drawer testD. McMurray testE. Valgus stress test

Age / Gender

Mechanism of injury/ Sport

Exam findings

Imaging Treatment Refer?

Tibial tubercle fracture

M>F14-16 yrs

Tubercle growth plate weak during puberty; sudden deceleration or quadriceps contraction fracture

Knee held in flexion, point tenderness+/- swelling

Lateral xray of knee shows fracture

Immobilize, non-weight bearing; Refer to ortho

Yes

Osgood-Schlatter M>F9-14yrs

Chronic excessive force on tibial tubercle; rapidly growing adolescents; jumping and squatting

Tenderness and swelling over tibial tubercle

Lateral knee xray can show swelling and fragmentation of tibial tubercle

Rest, ice, NSAIDsSelf-limitedResolves once growth plates close

If conservative management fails

ACL tear F>M Sudden deceleration and twisting of the knee (cutting and pivoting)

+Lachman+anterior drawerEarly: Inability to bear weight, effusion, Late: knee instability

Xray: avulsion fx of lateral tibial plateau

MRI

Immobilizer, non-weight bearing

Elective outpatient referral in 7-10days

MCL tear M=F Valgus force on the knee with foot planted; often during collision or awkward fall

+Valgus stress testing shows laxity of MCL

Medial knee pain

MRI for equivocal cases

Rest, ice, NSAIDs, crutchesHinged knee-brace acutely, followed by early mobilization and PT

If conservative management fails

ACL tear: Physical Exam

Anterior drawer test Leg at 90 degrees Foot stabilized Grasp proximal tibia Pull leg forward

Lachman test Flex knee to 15-30

degrees Pull tibia forward with

one hand Hold femur stationary

Excessive anterior tibial forward motion on either test signifies ACL injury

Age / Gender

Mechanism of injury/ Sport

Exam findings

Imaging Treatment Refer?

Tibial tubercle fracture

M>F14-16 yrs

Tubercle growth plate weak during puberty; sudden deceleration or quadriceps contraction fracture

Knee held in flexion, point tenderness+/- swelling

Lateral xray of knee shows fracture

Immobilize, non-weight bearing; Refer to ortho

Yes

Osgood-Schlatter M>F9-14yrs

Chronic excessive force on tibial tubercle; rapidly growing adolescents; jumping and squatting

Tenderness and swelling over tibial tubercle

Lateral knee xray can show swelling and fragmentation of tibial tubercle

Rest, ice, NSAIDsSelf-limitedResolves once growth plates close

If conservative management fails

ACL tear F>M Sudden deceleration and twisting of the knee (cutting and pivoting)

+Lachman+anterior drawerEarly: Inability to bear weight, effusion, Late: knee instability

Xray: avulsion fx of lateral tibial plateau

MRI

Immobilizer, non-weight bearing

Elective outpatient referral in 7-10days

MCL tear M=F Valgus force on the knee with foot planted; often during collision or awkward fall

+Valgus stress testing shows laxity of MCL

Medial knee pain

MRI for equivocal cases

Rest, ice, NSAIDs, crutchesHinged knee-brace acutely, followed by early mobilization and PT

If conservative management fails

MCL tear – Physical Exam

Medial-sided knee pain Varying degree of

tenderness to palpation Effusion and local

ecchymosis may be present

ROM is normal MCL integrity tested by

valgus stress testing in full extension AND at 30 degrees of flexion

text

At extension: knee remains stable as long as the cruciate ligaments and posterior capsule are intactAt 30 degrees: MCL is primary stabilizer

Question #14Which of the following is an indication to refer a

patient with prepatellar bursitis to an orthopedic surgeon?

A. Swelling superficial to the patella that extends outward > 1cm

B. Negative findings on an xrayC. Patients with significant erythema,

tenderness, and swelling with a fever of 103.20F

D. Pain despite treatment with tylenol x 1 dayE. The biggest game of the season is tomorrow

and they really really want to play

Age / Gender

Mechanism of injury/ Sport

Exam findings

Imaging Treatment Refer?

Discoid meniscus M=F4-9yrs

Abnormally shaped meniscusNo history of traumaSymptoms exacerbated by physical activity

‘snapping’ or ‘popping’ of knee+McMurray test

Xrays normalMRI shows ‘bow-tie’ shape of meniscus

Supportive; refer if pain prevents physical or daily activity

Yes if pain prevents physical or daily activity

Osteochondritis dissecans

M>F10-13yrs

Unknown cause; Destruction of subchondral bone on undersurface of normal articular cartilage Necrosis of articular surface of joint Separation of overlying cartilageCan result in fragmentation of the affected bone

Stable: Joint pain aggravated by activity;Unstable: Have feeling of joint instability but none found on exam; +/- point tenderness,+/- effusion

Xrays to evaluate joint surfaces and patellaMRI (test of choice) shows extent of lesion

Stable lesion: activity modification, NSAIDsUnstable: refer for surgery

For unstable lesions or failure of conservative management

Prepatellar bursitis M>F Repeated kneeling (baseball catcher, wrestler) leads to inflammation of the prepatellar bursa

Swelling, tenderness, erythema of prepatellaPain with knee flexion

Not useful Rest, ice, compressive dressingLarge fluid collection can be aspirated

For septic bursitis or failure of conservative management

Discoid Meniscus McMurray test

Usually positive with meniscal abnormalities

Hip flexed to 90 degrees and knee maximally flexed

Knee extended gradually while applying valgus force and external rotation of tibia

Provides axial load and rotational force to the meniscus painful

Age / Gender

Mechanism of injury/ Sport

Exam findings

Imaging Treatment Refer?

Discoid meniscus M=F4-9yrs

Abnormally shaped meniscusNo history of traumaSymptoms exacerbated by physical activity

‘snapping’ or ‘popping’ of knee+McMurray test

Xrays normalMRI shows ‘bow-tie’ shape of meniscus

Supportive; refer if pain prevents physical or daily activity

Yes if pain prevents physical or daily activity

Osteochondritis dissecans

M>F10-13yrs

Unknown cause; Destruction of subchondral bone on undersurface of normal articular cartilage Necrosis of articular surface of joint Separation of overlying cartilageCan result in fragmentation of the affected bone

Stable: Joint pain aggravated by activity;Unstable: Have feeling of joint instability but none found on exam; +/- point tenderness,+/- effusion

Xrays to evaluate joint surfaces and patellaMRI (test of choice) shows extent of lesion

Stable lesion: activity modification, NSAIDsUnstable: refer for surgery

For unstable lesions or failure of conservative management

Prepatellar bursitis M>F Repeated kneeling (baseball catcher, wrestler) leads to inflammation of the prepatellar bursa

Swelling, tenderness, erythema of prepatellaPain with knee flexion

Not useful Rest, ice, compressive dressingLarge fluid collection can be aspirated

For septic bursitis or failure of conservative management

Patellofemoral Syndrome (PFS) Common cause of

chronic anterior knee pain Athletes who engage in

running, jumping, squatting**

Females> males Wider pelvis higher Q

angle more susceptible to PFS

Q angle Angle between a line

from the anterior superior iliac spine (ASIS) to the patella and a line from the patella to the tibial tubercle

Question #15

Of the following, which is not an initial treatment for Patellofemoral Syndrome?

A. Knee bracing and patellar tapingB. NSAIDsC. Outpatient referral to orthopedics

in 7-10 daysD. Physical therapyE. Core strengthening

Present with vague anterior knee pain Worse with activities that require knee flexion with weight

bearing Stairs, deep squatting, crawling

Diagnosis/ Imaging History and physical exam Imaging only useful to exclude other conditions

Treatment: Goal to improve patellar tracking Knee bracing, patellar taping PT: iliotibial band stretching, medial quad strengthening Core strengthening to improve pelvic control and

minimize medial knee deviation Refer to Ortho

If 4-6 months of PT do not provide relief

Patellofemoral Syndrome (PFS)

Extra content specs Overuse injuries Eye injuries Protective equipment Shoulder, Elbow, Wrist injuries

Overuse Injuries Overuse injuries are common in child athletes Characterized by repetitive microtrauma to

bone and tendon Gymnasts sustain foot and hand injuries due to

frequent load bearing during handstands, etc Overuse injury of the radius is common

Major concern is radial epiphysitis which may result in impaired linear growth of the affected bone**

Necrosis of the navicular bone is seen with fracture (usually occult) May also cause impaired growth of the wrist in children

and limit movement Watch for Salter Harris fractures

Overuse Injuries

Treatment: Rest, ice, and anti-inflammatory

medications Exercise that does not aggravate the

injury but preserves conditioning may be continued during recovery Can be prescribed for the athlete by the

coach and trainer, often in consultation with a sports medicine specialist

Eye Trauma Evaluation of an eye injury must happen before return

to play** Initial evaluation:

Identification of the timing, mechanism, and location of the injury

Assessment of visual symptoms Change in vision? Flashing lights or floaters?

Physical examination Initial management directed at preventing any

increase in intraocular pressure** NO direct pressure to the eye

Eye protection using an eye shield Patient positioning

Recumbent positioning with the head of the bed at 45 degrees Avoid meds that increase IOP

I.e. Ketamine

Eye Trauma Eye examination:

Inspect the face/lids for injury Lid contusions and lacerations should raise suspicion for globe or

orbital injury Palpate rim of the orbit for deformities EOM Evert the lid to look for foreign material Visual acuity with a Snellen chart Evaluation of the globe:

Inspection of the conjunctivae for foreign bodies and hemorrhage Cornea: assessed with a penlight and fluorescein stain/blue light for

abrasions or evidence of penetration Pupils: reaction and symmetry

Abnormally shaped pupil strongly suggests the presence of an open globe** Anterior chamber/iris/lens should be inspected with a penlight and, if

possible, slitlamp Look for hyphema, uveitis, or lens dislocation

Lastly, the fundus should be examined

Hyphema Collection of blood in the anterior chamber of

the eye between the iris and the cornea Visual disturbances, photophobia, eye pain Nausea, vomiting, lethargy Treatment

Goals: Prevent rebleeding and prevent increased IOP

Consult Ophtho (this is an emergency) Protective eye SHIELD (not occlusive dressing) Recumbent positioning – head at 30-45o

No medications into the eye Avoid NSAIDs for potential effects of platelet

function

Protective Equipment Mouth injuries (along with other head

injuries) account for the majority (48%) of youth baseball injuries Injuries generally are caused by contact with

sports equipment (eg, the bat, the ball, and the base)

Other injuries Leg, groin, and chest Testicular injury: less common

Use of a protective cup in ALL sports is recommended to prevent testicular injury

Mouth Guards Even with the use of a helmet, mouth

guards protect further against injuries of teeth and oral mucosa

The American Association of Orthodontists recommends that mouth guards be used for the following sports: baseball, football, soccer, basketball,

wrestling, softball, ice and field hockey, volleyball, and lacrosse

Shoulder Dislocation Most are sports related Most involve anterior displacement of the humeral head

Resulting from posteriorly directed force on an abducted, extended arm

Arm is held slightly abducted and external rotation Humoral head may be palpated inferiorly to the mid-clavicle on

the affected side Can compress the axillary nerve

Numbness over the deltoid and inability to abduct or extend the shoulder

Initial Management Sling immobilization with a pillow or blanket Analgesics Xrays: AP, lateral , axillary views (axillary is most sensitive) Should be reduced urgently under procedural anesthesia Sling and swathed after reduction for 2-4 weeks

Elbow Dislocation Posterior elbow dislocation is the most common

joint dislocation seen in children Fall onto outstretched hand with flexed elbow Elbow pain and olecranon prominence on exam Can cause nerve injury

Most commonly affects the ulnar nerve (see in 10%) Decreased sensation over 5th finger, loss of wrist

flexion and finger abduction If seen need urgent reduction

Can cause brachial artery injury Decreased radial pulse, pallor, forarm paresthesias If seen urgent reduction

Acute management: Arm splinted, analgesia, referred emergently to ortho

Elbow pain “Little League Elbow” = elbow pain in skeletally

immature athlete who participates in “overhead sports” (baseball, softball, swimming, gymnastics) Apophysitis of the medial epicondyle Seen most commonly in 9-12yr old athletes

Swelling and tenderness on exam Xrays are typically normal

Can show hypertrophy or fragmentation of the medial epicondyle or subtle apophyseal widening

Treatment Rest for 4-6weeks Ice, oral analgesics Elbow brace for flexion contracture Once pain resolved completely, can slowing increase

throwing activities under supervision Most athletes return to play after 12 weeks

Scaphoid fracture Fall onto outstretched hand Tenderness over anatomical snuff box Initial xrays are often NORMAL Treatment:

Thumb spica splint Ice, analgesia Follow up with ortho and repeat films in 7-

10days High risk of malunion, nonunion, avascular

necrosis This type of fracture has a poor prognosis

YAY! WE’RE DONE THANKS!!!