Disclosures. Common Injuries In Sports Medicine UT 33 rd Annual Family Medicine Update June 14, Derek Worley MD, MPH CAQ Sports Medicine

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1 Common Injuries In Sports Medicine UT 33 rd Annual Family Medicine Update June 14, 2018 None Disclosures Derek Worley MD, MPH CAQ Sports Medicine Learning Objectives Identify common injuries in sports medicine Recognize how common sports injuries may present Choose proper imaging for injuries Apply appropriate management of injuries Biceps Tendinopathy Medial Epicondylitis Ulnar Collateral Ligament Injury Cubital Tunnel Syndrome Scaphoid Fracture De Quervain Tenosynovitis Patella Tendinopathy IT Band Friction Syndrome Achilles Tendonitis Prevalence: Age >60: 28% have full thickness tear Age >75: 65% have full thickness tear Mechanism of tear: Chronic degenerative tear Chronic impingement Acute avulsion injuries Supraspinatus, Infraspinatus, and Teres Minor: Make up majority of tears Associated with subacromial impingement Often a degenerative tear in older patients or a shoulder dislocation in patients > 40 yrs of age Subscapularis: Associated with subcoracoid impingement Often an acute avulsion in younger patients with a hyperabduction/external rotation injury 1

2 Ellman Classification of Partial-Thickness Tears: Grade I: <3mm (25%) Grade II: 3-6mm (25-50%) Grade III: >6mm (>50%) Insidious onset of pain exacerbated by overhead activities Pain located in deltoid region Night pain May have acute pain and weakness with a traumatic tear Loss of active ROM but intact passive ROM Supraspinatus: Weakness to resisted elevation in Jobe position Drop arm test Pain with Jobe test Infraspinatus: External rotation weakness at 0 degrees abduction ER lag sign Teres Minor: ER weakness at 90 degrees abduction and 90 degrees abduction Hornblower s sign Subscapularis: Internal rotation weakness at 0 degrees abduction Excessive passive ER Belly press Lift off X-rays: AP, Axillary, and Outlet view Findings:» Calcific tendinitis» Calcification in the coracohumeral ligament» Cystic changes in greater tuberosity» Proximal migration of humerus in chronic tears» Type III (hooked) acromion MRI: Diagnostic standard Evaluates size, shape, degree of retraction of tear, and muscle fatty atrophy Ultrasound: Dynamic evaluation Inexpensive User dependent 2

3 CT Arthrogram: Used when MRI contraindicated Rotator cuff tear present if dye leaks from glenohumeral joint into subacromial space Considerations: Activity and age of patient Mechanism of tear (degenerative or traumatic) Characteristics of tear Partial vs complete Articular sided vs bursal sided Bursal sided tears treated more aggressively Non-operative: Physical therapy Rotator cuff and scapular stabilization strengthening over 3-6 months NSAIDs Subacromial corticosteroid injection If impingement thought to be major cause of symptoms Avoid overhead activities Operative Indications: Acute full-thickness Bursal sided tears >3 mm (25%) Partial articular sided tears >50% Biceps Tendinopathy Distal biceps ruptures are rare (3%) More likely tendinopathy Slow onset of anterior pain, especially with supination and pronation Elbow flexed to 90 with passive supination and pronation should reveal a normal piston-like movement of biceps muscle belly Absence of this motion indicates a complete tear Biceps Tendinopathy Resisted supination may cause pain in antecubital fossa Hook Test: 3

4 Biceps Tendinopathy MRI or MSK US can determine continuity and changes in caliber of the tendon NSAIDs, physical therapy, possible injections Medial Epicondylitis (Golfer s Elbow) Tendinopathy of common flexor tendon Occurs in those with repetitive valgus stress and flexion at the elbow May also be caused by repetitive wrist flexion and pronation insidious onset of pain at medial elbow with possible grip strength weakness Medial Epicondylitis (Golfer s Elbow) Tenderness 5-10 mm distal and anterior to medial epicondyle Pain with resisted forearm pronation and wrist flexion Ultrasound: >90 % sensitivity and specificity MRI without contrast Medial Epicondylitis (Golfer s Elbow) NSAIDs Activity Modification PT with passive stretching Counterforce bracing Peritendinous corticosteroid injections? Extracorporeal shockwave therapy Operative debridement if up to 6 months of nonoperative management that fails Commonly occur in athletes participating in overhead throwing, such as baseball, javelin, and volleyball Anterior bundle is the primary restraint to valgus stress Acute injuries usually report the sensation of a pop followed by immediate pain and possible bruising Decreased throwing performance Loss of velocity Loss of accuracy Tenderness over UCL Sensitivity of 81-94% Specificity of 22% 4

5 Moving Valgus Stress Test: Milking Maneuver: Pull patient s thumb with forearm supinated, shoulder extended, and elbow flexed past 90 Modified with elbow at 70 flexion MRI Arthrogram Diagnose full thickness and partial thickness tears Look for capsular T-sign with contrast extravasation MRI without contrast Thickened ligament Calcifications Tears Dynamic Ultrasound Laxity with valgus stress Non-operative: 6 weeks of rest from throwing PT for flexor-pronator strengthening Once symptoms resolve a graduated throwing program Operative: UCL anterior band ligament reconstruction (Tommy John Surgery) High level throwers Failure of non-operative treatment Cubital Tunnel Syndrome Compressive or traction neuropathy of the ulnar nerve as it passes through the cubital tunnel of the elbow 2 nd most common compression neuropathy of upper extremity 60% of patients with medial epicondylitis may have a concomitant compressive ulnar neuropathy Medial elbow pain with repetitive activity Usually associated with numbness and tingling in the ulnar border of the forearm and hand May have nighttime pain from sleeping with elbow fully flexed Cubital Tunnel Syndrome Exam should include cervical spine to r/o other compressive neuropathies Tinel Sign: 44-75% sensitivity % specificity Wartenberg Sign: Inability to adduct the little finger Clawhand Deformity Ulnar hand should be palpated in the cubital tunnel during flexion and extension to detect any subluxation or dislocation of the nerve 5

6 Cubital Tunnel Syndrome Diagnostic Studies: EMG: Conduction velocity <50 m/sec across elbow Low amplitudes of sensory nerve action potentials and compound muscle action potentials MRI without contrast: May identify site of nerve entrapment Cubital Tunnel Syndrome Non-operative: NSAIDs Activity modification Nighttime bracing in 45 extension with forearm in neutral rotation Operative: Ulnar nerve decompression with or without transposition Scaphoid Fracture Most common carpal bone fracture Most patients present quickly after a fall but some may have a delayed presentation because the pain initially improves Typical history is fall on outstretched hand with wrist dorsiflexed and radially deviated Swollen wrist Tenderness over distal radius, scaphoid tubercle on volar aspect, and anatomic snuff box May have painful wrist extension and loss of grip strength Scaphoid Fracture X-rays: AP & lateral Scaphoid view 30 wrist extension with 20 ulnar deviation 45 pronation view Initial x-rays that are negative may be repeat in days May show sclerosis at that time Protect with thumb spica cast until repeat x-rays are determined to be negative Bone Scan: May diagnose occult fractures at 72 hours Sensitivity 100% Specificity 98% May have false positives MRI without contrast: Most sensitive for occult fractures <24 hours Access vascular status of bone Scaphoid Fracture Depends on anatomical location and displacement Scaphoid Fracture Thumb Spica Cast Immobilization Stable non-displaced fracture Normal x-rays but high level of suspicion (reevaluate in days) Duration: Distal waist 3 months Mid-waist 4 months Proximal 1/3 5 months 6

7 Scaphoid Fracture Operative: Proximal pole fracture Displacement > 1 mm Fracture associated with perilunate dislocation Comminuted fracture Unstable vertical or oblique fracture De Quervain Tenosynovitis Affects the extensor pollicus brevis and abductor pollicus longus tendons Form the lateral border of the anatomic snuff box Inside a synovial sheath in the 1 st extensor compartment Tendons move the thumb into radial abduction De Quervain Tenosynovitis Subacute radial wrist pain at the thumb base and into the distal radius Patients may identify a new or repetitive handbased activity More common in women Age 30 to 50 De Quervain Tenosynovitis Minimally swollen wrist Tenderness over radial tubercle and soft tissues of anatomic snuffbox Thumb motion is painful Finkelstein Test: Make a fist over the thumb and move hand into ulnar deviation Grind Test: Axial compression of thumb and slight rotation should be negative Positive in 1 st CMC osteoarthritis De Quervain Tenosynovitis Not required X-ray can help rule out 1 st CMC OA or carpal bone pathology De Quervain Tenosynovitis Rest or activity modification NSAIDs Thumb spica splint Steroid injection into first dorsal compartment 7

8 Patellar Tendinopathy Known as jumper s knee More common in adolescents/young adults Quadriceps tendinopathy is more common in older adults Caused by repetitive, forceful, eccentric contraction of the extensor mechanism Patellar Tendinopathy Anterior knee pain at inferior border of patella Initially following activity as progresses may have pain during activity May have swelling over tendon Tenderness at inferior border of patella Pain with resisted knee extension Patellar Tendinopathy X-rays: AP, Lateral, and Sunrise May show inferior traction spur (enthesophyte) in chronic cases Ultrasound: Thickening of tendon Hypoechoic areas MRI: Tendon thickening Increased signal intensity on T1 & T2 images Patellar Tendinopathy Nonoperative: Rest and/or activity modification NSAIDs Physical Therapy Stretching of quadriceps and hamstrings Eccentric exercise Patellar tendon strap (Chopat s) Reduces tension across tendon Ultrasound guided needle tenotomy and/or PRP IT Band Friction Syndrome IT Band Friction Syndrome Caused by excessive friction between the IT band and lateral femoral condyle Common in runners and cyclists Risk Factors: Sudden change in training intensity Poor shoe support Tight IT band Excessive foot pronation Disparity between quadriceps and hamstring strength Pain predominantly over the lateral femoral condyle Usually relieved by rest May have swelling and tenderness over lateral femoral condyle Pain reproduced with single leg squat Ober Test: Detects IT band tightness Lateral decubitus positon with symptomatic side up, knee flexed to 90º Hip brought from flexion and abduction into extension and adduction Positive if pain, tightness, or clicking over IT band 8

9 IT Band Friction Syndrome X-rays: AP, Lateral, and Sunrise Usually normal May show associated medial compartment narrowing and/or Patellar malalignment MRI: R/O lateral meniscal tear or LCL sprain Signal changes in lateral synovial recess, IT band, or periosteum IT Band Friction Syndrome Nonoperative: Rest and/or activity modification Oral and/or topical NSAIDs Corticosteroid injection Physical therapy Stretching of IT band, lateral fascia, and gluteal muscles Strengthen hip abductors Change shoes every miles Avoid sudden increases in mileage Achilles Tendonitis Pain and tendon thickening at insertion of Achilles tendon More common in middle-age and elderly patients with a tight heel cord Achilles Tendonitis Posterior heel pain, swelling, burning, and stiffness Shoe wear may cause pain Progressive bony enlargement of calcaneous at insertion site Midline tenderness at insertion of Achilles tendon Negative Thompson squeeze test Achilles Tendonitis X-ray: Lateral x-ray may show intratendonous calcification and/or Haglund s deformity MRI: Can demonstrate amount of degeneration Achilles Tendonitis Nonoperative: Activity modification Physical therapy Eccentric training Gastrocnemius-soleus stretching Heel lift NSAIDs (oral and/or topical) Avoid steroid injection due to risk of Achilles tendon rupture 9

10 ATFL is most commonly involved ligament Mechanism is plantar flexion and inversion CFL is 2nd most common ligament injury in lateral ankle sprains Mechanism is dorsiflexion and inversion Classification Grade I: No ligament disruption, minimal ecchymosis and swelling, limited pain with weight bearing Grade II: Stretching of ligament, moderate ecchymosis and swelling, mild pain with weight bearing Grade III: Complete tear of ligament, severe ecchymosis and swelling, sever pain with weight bearing Pain with weight bearing Sense of instability Catching or popping sensation Tenderness and swelling over involved ligaments Anterior Drawer test: ATFL: laxity in plantar flexion CFL: Laxity in dorsiflexion Eversion/Inversion Laxity Ottawa Ankle Rules: Inability to bear weight Medial or lateral malleolus point tenderness 5 th metatarsal base tenderness Navicular tenderness X-rays: AP, Lateral, & Mortise Varus stress view: may diagnose injury to ATFL or CFL MRI: Consider if pain persists 8 weeks following sprain Useful to R/O peroneal tendon pathology and/or osteochondral injury Nonoperative: RICE NSAIDs May require short period (< 1 week) of weight bearing immobilization in a walking boot or walking cast Early mobilization facilitates a better recovery Physical Therapy: Once swelling and pain subside and patient has regained full ROM focus on neuromuscular training with a focus on peroneal muscles and proprioception training Functional bracing Restrict inversion and eversion During exercise for 6-12 months after injury to improve stability and prevent recurrence Operative: Indications: Grade I-III with continued pain and instability despite conservative management Grade I-III with bony avulsion 10

11 References Prado et al. A Comparative, Prosepective, and Randomized Study of Two Conservative Treatment Protocols for First-Episode Lateral Ankle Ligament Injuries. Foot Ankle Int Mar; 35(3): Kemler et al. A Systematic Review On The Treatment of Acute : Brace Versus Other Functional Treatment Types. Sports Med Mar 1;41(3): Pihlajamaki et al. Surgical Versus Functional Treatment for Acute Ruptures of the Lateral Ligament Complex of the Ankle in Young Men: A Randomized Controlled Trial. J Bone Joint Surg Am Oct 20;92 (14): Kang et al. Insertional Achilles Tendinits and Haglund s Deformity. Foot Ankle Int Jun;33 (6): Vora et al. Tendinopathy of the Main Body of the Achilles Tendon. Foot Ankle Clin Jun;10(2): Khaund & Flynn. Iiliotibial Band Syndrome: A Common Source of Knee Pain. American Family Physician April; 71 (8): Panni et al. Overuse Injuries of the Extensor Mechanism in Athletes. Clin Sports Med Jul;21(3) Witvrouw et al. Intrinsic Risk Factors for the Development of Patellar Tendinitis in an Athletic Population. A Two-Year Prospective Study. Am J Sports Med Mar-Apr;29(2): Arnold & Moody. Common Running Injuries: Evaluation and Management. American Family Physician April;97(8) Shehab & Mirabelli. Evaluation and Diagnosis of Wrist Pain: A Case-Based Approach. American Family Physician April;87(8) Ring et al. Acute Fractures of the Scaphoid. J Am Acad Orthop Surg Jul-Aug;8(4): Gaebler et al. Magnetic Resonance Imaging of Occult Scaphoid Fractures. J Traum. 1996;41 (1):73-6. Kane et al. Evaluation of Elbow Pain in Adults. American Family Physician April; 89(8): Hariri & Sarfran. Ulnar Collateral Ligament Injury in the Overhead Athlete. Clin Sports Med Oct;29(4): Cain et al. Elbow Injuries in Throwing Athletes: A Current Concepts Review. Am J Sports Med Jul-Aug; 31 4): Wolff et al. Parital-Thickness. J Am Acad Orthop Surg Dec;14(13): Warner et al. Diagnosis and Treatment of Anteriorsuperior. J Shoulder Elbow Surg Jan-Feb;10(1): McConville & Lannotti. Partial Thickness Tears of the Rotator Cuff: Evaluation and Management. J Am Acad Orthop Surg Jan;7(1):