(My) 2017 Top Sports Medicine Conditions in Women

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1 Disclosures (My) 2017 Top Sports Medicine Conditions in Women None. UCSF CME:Controversies in Womens Health Carlin Senter, MD Associate Professor Primary Care Sports Medicine UCSF Medicine and Orthopaedics Learning objectives Upon completion of this session, participants should be able to: 1. List 3 indications for knee arthroscopy 2. List 5 treatment modalities for knee osteoarthritis 3. Name 2 conditions in which the shoulder has limited active and passive range of motion 4. Define the female athlete triad 5. Write an exercise prescription Case #1 60 y/o woman presents with 3 months of medial knee pain. (+) swelling, and instability. No frank locking. Pain is worse with weight bearing. Better with rest, ice, and NSAIDs. She brings a knee MRI for your review. Exam: Neutral knee alignment when standing, tender medial joint line + medial femoral condyle + medial tibial plateau. Small effusion. ROM 0-120, limited by pain. Mild crepitus. (+) medial Mcmurray, medial knee pain with squat. No ligamentous laxity.

2 Case #1: MRI results Small effusion Moderate chondrosis medial femoral condyle and medial tibial plateau Degenerative medial meniscus tear Which of the following would you recommend? A. Refer for arthroscopic debridement of meniscus tear and lavage B. Nonoperative knee OA program C. Refer for total knee replacement Case #1 60 y/o woman presents with 3 months of medial knee pain. (+) swelling, and instability. No frank locking. Pain is worse with weight bearing. Better with rest, ice, and NSAIDs. She brings a knee MRI for your review. Exam: Neutral knee alignment when standing, tender medial joint line + medial femoral condyle + medial tibial plateau. Small effusion. ROM 0-120, limited by pain. Mild crepitus. (+) medial McMurray, medial knee pain with squat. No ligamentous laxity. Clinical criteria for diagnosis of knee OA Altman R et al. Arthritis Rheum Aug;29(8):

3 Clinical criteria for diagnosis of knee OA Altman R et al. Arthritis Rheum Aug;29(8):

4 Arthritis epidemiology Most common type = osteoarthritis Affects 23% of all adults in the United States ( > 54 million people) More common in women (24%) than men (18%) Affects ½ of US adults with heart disease ½ of US adults with diabetes 1/3 of US adults with obesity Osteoarthritis was the 2 nd most expensive health condition treated in US hospitals in Accessed November 18, /22/2017 McAlindon TE et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage Mar;22(3): Does arthroscopic partial meniscectomy (APM) help middle aged patients with osteoarthritis +/- degenerative meniscus tear? Arthroscopy not indicated for knee OA as no more effective than non operative care (Mosely JB et al, NEJM 2002; Kirkley A et al. NEJM 2008) ¾ studies show no significant difference between APM + PT versus PT alone (Gauffin H et al. Osteoarthritis Cartilage 2014; Herrlin SV et al. Knee Surg Sports Traumatol Arthrosc 2013; Katz JN et al. NEJM 2013; Yim JH et al. AJSM 2013.) Limitation: difficult to interpret due to cross-over (30%) before assessment of the primary outcome Factors associated with crossover from PT to APM: shorter duration of symptoms and higher initial pain score (Katz JN et al. JBJS 2016.) Take-home points: knee OA, meniscus tears Degenerative meniscus tear is part of the natural history of osteoarthritis Treat as osteoarthritis initially with non surgical knee OA program Imaging: Start with x-ray. Consider referral vs MRI if exam c/w meniscus tear and not improving with PT Could consider arthroscopic meniscus surgery if weight loss, PT, medications, injections not helping or if patient prefers surgical treatment.

5 McAlindon TE et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage Mar;22(3):

6 Indications for knee arthroscopy Acute (not degenerative) meniscus tear, no arthritis Locked or locking knee: Bucket handle meniscus tear or loose body Ligament tear ACL reconstruction MCL often treated conservatively but sometimes reconstructed PCL depends on whether or not other structures injured LCL reconstruction (rare injury) Which of the following would you recommend? 60 y/o woman with 3 months knee pain due to medial compartment OA and degenerative tear of medical meniscus. A. Refer for arthroscopic debridement of meniscus tear and lavage B. Nonoperative knee OA program C. Refer for total knee replacement Case #2 50 y/o RHD woman with type 2 diabetes presents with 3 months of severe R shoulder pain. No injury. Waking up at night due to pain. Shoulder feels very stiff. She is having trouble reaching behind and raising arm above head. On exam she has no muscle atrophy and no point tenderness. There is decreased active and passive range of motion of the right shoulder. Her rotator cuff strength is 5/5 though difficult to perform due to limited range of motion and pain. R shoulder x-rays are normal. How would you treat this patient? A.Provide R shoulder sling to use for comfort. B.Provide shoulder steroid injection to reduce pain. C.Obtain shoulder MRI. D.Refer to surgeon for arthroscopy.

7 Adhesive capsulitis Shoulder: diagnosis driven exam Active ROM Normal Decreased Rotator cuff disease Labral tear Biceps tendinitis AC joint OA Normal Passive ROM Decreased althgate/images/si jpg Adapted from: O'Kane and Toresdahl. The evidencedbased shoulder evaluation. Cur Sports Med Rep Frozen shoulder Normal Xray Abnormal GH joint arthritis Shoulder active range of motion Shoulder active range of motion Abduction Forward flexion External rotation Internal rotation Internal rotation

8 Limited ER key finding Adhesive capsulitis is a clinical diagnosis No need for MRI X-rays helpful to r/o glenohumeral joint arthritis X-rays courtesy of Dr. Ben Ma 3 stages of adhesive capsulitis Treatment for adhesive capsulitis Freezing Frozen Thawing 3-9 months pain ROM Pain at rest, sleep 4-12 months pain Stable, decreased ROM months Gradual ROM Resolution Average time to resolution: 1-3 years Associated w/diabetes: A1c or fasting blood sugar Pain control: NSAIDs or injected corticosteroids Does not change disease course Does help significantly with pain control +/- physical therapy to help restore ROM Capsular distention injections Surgery (rarely) Manske and Prohaska, Curr Rev Musculoskeletal Med, Griesser MJ et al. Adhesive capsulitis a systematic review of intraarticular injections. J Bone Joint Surg Am. Sep 2011.

9 How would you treat this patient? 50 y/o RHD woman with 3 months severe R shoulder pain. Limited active and passive range of motion. Normal x-rays. A. Provide R shoulder sling to use for comfort. B. Provide shoulder steroid injection to reduce pain. C. Obtain shoulder MRI. D. Refer to surgeon for arthroscopy. Case #3 20 y/o collegiate cross country athlete Presents to training room with right groin pain Started a few weeks ago, getting worse gradually Still able to run but pain gets worse the more she runs, hard to lift her leg due to pain Differential diagnosis groin pain in runner 5 questions for every runner with hip pain Hip flexor strain Femoral acetabular impingement +/- hip labral tear Sports hernia Osteitis pubis Femoral neck stress fracture GI/gyn problems Falvey EC et al, BJSM Training: increased mileage? 2. Nutrition: Calories in versus calories out? History of eating d/o? Dietary restrictions? 3. History of stress fractures? 4. Family history of osteoporosis? 5. Menstrual history?

10 Our patient Increased mileage from 30 to 60 miles/week in last month without increased caloric intake No dietary restrictions or h/o eating d/o (+) h/o tibial stress fracture in high school No family history osteoporosis Menses regular until college but none since freshman year (18 months) What s your leading diagnosis? A. Hip flexor strain B. Femoral acetabular impingement C. Sports hernia D. Osteitis pubis E. Femoral neck stress fracture F. GI / gyn problem High index of suspicion to prevent bad outcome Risk factors for bone stress injury in female athletes Low bone mineral density (Bennell, 1996; Kelsey, 2007; Myburgh, 1990; Goolsby, 2008) Delayed onset of menses and/or missing periods (Goolsby,2008; Bennell, 1996; Myburgh, 1990) Lower dietary calcium (Kelsey, 2007) Lower dietary fat (Bennell, 1996) History of stress fracture (Goolsby, 2008; Kelsey, 2007) Restrictive eating (Goolsby, 2008; Bennell, 1996)

11 Female athlete triad Female athlete triad = PATHOLOGY Low energy availability with or without eating d/o Suboptimal energy availability Low bone density Healthy bones Healthy energy status Irregular menses OPTIMAL HEALTH Healthy menstrual cycles the interrelationships between energy availability, menstrual function, and bone mineral density. Osteoporosis Amenorrhea Nattiv A et al, ACSM Position Stand, Nattiv A et al, ACSM Position Stand, Triad Consensus Panel Screening Questions Female athlete triad treatment Menstrual periods: LMP? # in past 12 months? Age of menarche Taking any female hormones, OCPs? Weight Do you worry about your weight? Are you trying to or has anyone recommended you gain or lose weight? Are you on a special diet or do you avoid certain foods? Have you ever had an eating disorder? Have you ever had a stress fracture? Have you ever been told you have low bone density? Mary Jane De Souza et al. Br J Sports Med 2014;48:289 Best treatment = prevention Screen for risk factors Finding 1 risk factor should prompt eval for others Increase energy availability Increase dietary intake Decrease exercise Has been shown to restore menses Has been shown to increase bone density Estrogen: does not improve BMD as much as if menses are restored with increased energy availability Multidisciplinary approach Nattiv A et al, ACSM Position Stand, 2007.

12 Female athlete triad resource: Case #4 63 y/o woman presents for annual exam. Takes no medications. Busy job, mostly on computer. Doesn t have time for exercise but she walks 5 minutes to and from work 5 days/week. BP 140/80, HR 80, Height: 5 3, weight 170# (BMI 30) Labs: HgA1c 6.3% Total cholesterol 192, TG 119, HDL 50, LDL 118 TSH normal Definitions Strong evidence that physical activity associated with lower risk of Physical activity: any body movement that results in energy expenditure (exercise, activities of daily living, active transportation) Exercise: one kind of physical activity that is planned, structured, repetitive with objective to improve or maintain physical fitness. Coronary artery disease Stroke High blood pressure High cholesterol Metabolic syndrome Cognitive impairment Type 2 diabetes Colon cancer Breast cancer Falls Weight gain Depression ACSM Position Stand on Prescribing Exercise, Med Sci Sports Ex, US Dept Health and Human Services. Physical Activity Guidelines Advisory Committee Report, 2008: Accessed 11/18/2017.

13 Percent of adults who achieve at least 150 minutes a week of moderate-intensity aerobic physical activity or 75 minutes a week of vigorous-intensity aerobic activity (or an equivalent combination) 2015 The exercise prescription: What s the right dose of activity? pao_dtm/rdpage.aspx?rd Report=DNPAO_DTM. ExploreByTopic&islClass =PA&islTopic=PA1&go =GO. Accessed 11/18/17. Credit: Piotr Redlinski for The New York Times Physical activity recommendations: 4 types of activities Cardiovascular Strength Balance Flexibility Physical activity recommendations: components of each activity Frequency Intensity Time Type

14 Estimating exercise intensity Low Moderate Vigorous HR <50% max 50-70% max >70% max Talk test Can talk and sing Can talk but not sing Borg rating of perceived exertion 9 very light (slow walk 11 light 13 somewhat hard 15 hard (very heavy, tired) Can only say a few words before pause for breath 17- very hard 19 extremely hard 20 - max Rate of perceived exertion x 10 = Heart rate Good way to measure intensity for person on medications that affect the heart rate (metoprolol, other beta blockers). ACSM Position Stand on Prescribing Exercise, Med Sci Sports Ex, Exercise prescription: Combine activity with components CV fitness recommendations Cardiovascular Strength Balance Flexibility Frequency Intensity Time Type Frequency Intensity Time Type 5x/week Moderate 30 minutes Major muscle groups OR Frequency Intensity Time Type 3x/week Vigorous 20 minutes Major muscle groups Accessed 11/18/17. ACSM Position Stand on Prescribing Exercise, Med Sci Sports Ex, 2011.

15 Strength recommendations Frequency Intensity Time Type 2-3d/week Novice: 40-50% Experienced: 80% Unknown All major muscle groups Balance recommendations Frequency Intensity Time Type 2-3d/week Unknown 20 minutes Tai Chi, tennis, yoga, surfing Accessed 11/18/17. ACSM Position Stand on Prescribing Exercise, Med Sci Sports Ex, Accessed 11/18/17. ACSM Position Stand on Prescribing Exercise, Med Sci Sports Ex, Flexibility recommendations Frequency Intensity Time Type 2-3d/week Stretch to feeling of tightness Hold seconds All major muscletendon units Accessed 11/18/17. ACSM Position Stand on Prescribing Exercise, Med Sci Sports Ex, Age-adjusted all-cause death rate per 10,000 person-years Medicine & Science in Sports and Exercise, 2009.

16 Estimated daily time spent in different contexts of energy expenditure among adults, based on the National Health and Nutrition Examination Survey. Light time=24 MVPA Sleep Sedentary time. MVPA indicates moderate to vigorous physical activity. Think of sedentary behavior and physical activity as 2 factors as separate and unique determinants of health Insufficient physical activity predicts premature cardiovascular disease and mortality Prospective evidence suggests that sedentary behavior could be a risk factor for cardiovascular disease, diabetes and all-cause mortality Estimated that adults spend 6 8 hours /day in sedentary behavior Those who met physical activity guidelines had similar # sedentary hours to those who did not Association between TV viewing time and sedentary behavior Prevalence is greater in older adults Data conflicts regarding differences in sedentary behavior by sex or race/ethnicity Circulation. 2016;134:e262-e279 Circulation. 2016;134:e262-e279 Interventions to reduce sedentary behavior Activity-permissive workstation (stand, walk or pedal while working): decreased sedentary behavior by 77 minutes in 8 hour day (Neuhaus M et al. Reducing occupational sedentary time: a systematic review and meta-analysis of evidence on activity-permissive workstations. Obes Rev. 2014;15: ) Smartphone apps to monitor and interrupt sedentary behavior in real time significantly decreased sedentary time (Bond DS et al. B-MOBILE: a smartphone-based intervention to reduce sedentary time in overweight/obese individuals: a withinsubjects experimental trial. PLoS One. 2014;9:e ) Exercise prescription resources

17 Estimated daily time spent in different contexts of energy expenditure among adults, based on the National Health and Nutrition Examination Survey. Light time=24 MVPA Sleep Sedentary time. MVPA indicates moderate to vigorous physical activity. Circulation. 2016;134:e262-e279

18 Accessed 11/18/ Accessed 11/18/2017. (My) 2017 Top Sports Medicine Conditions in Women 1.Arthritis 2.Frozen shoulder 3.Female athlete triad 4.Physical inactivity

19 Take-home points 1. List 3 indications for knee arthroscopy 2. List 5 treatment modalities for knee osteoarthritis 3. Name 2 conditions in which the shoulder has limited active and passive range of motion 4. Define the female athlete triad 5. Write an exercise prescription

20 Female athlete triad: Cumulative risk assessment Mary Jane De Souza et al. Br J Sports Med 2014;48:289

21 Female Athlete Triad: Clearance and Return-to-Play (RTP) Guidelines by Medical Risk Stratification. *Cumulative Risk Score determined by summing the score of each risk factor (low, moderate, high risk) from the Cumulative Risk Assessment. Mary Jane De Souza et al. Br J Sports Med 2014;48:289