Challenges in Return to Play. Emily Harold, MD

Transcription

1 Challenges in Return to Play Emily Harold, MD

2 Learning Objectives Learn pediatric evidence regarding return to activity Develop strategies to aid in return to play decision making

3 Goals of return to play Safe return to at risk activity

4 young athletes with musculoskeletal and cervical spine injuries, should not return to play until they have full range of motion, resolution of pain, normal strength, psychological readiness, and the ability to demonstrate adequate sport-specific skills 1 1 Canty, Greg et al. Pediatr. Review 2015 Oct;36 (10),

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9 What return to play really is. Shared decision making that is based on what is the worst possible outcome of returning to play combined with the level of risk the athlete is willing to accept

10 Case #1 17 yo senior female soccer player with progressive pain in her right foot. Started out as pain after hard practices and games but the last 2 weeks has had pain with all athletic activity and some pain with walking at school. She has participated fully in soccer. PE: Normal gait Normal pain free R ankle motion Mild swelling dorsal foot overlying the 4 th metatarsal with pinpoint tenderness Pain with metatarsal squeeze

11 4 th metatarsal stress fracture CAN SHE PLAY?

12 Case #2 17 yo senior female soccer player with progressive pain in her right tibia. Started out as pain after hard practices and games but the last 2 weeks has had pain with all athletic activity and some pain with walking at school. She has participated fully in soccer. PE: Normal gait Normal pain free R ankle motion, pain free R knee motion No leg swelling Tenderness over the anterior tibia to palpation

13 Anterior Tibia Stress Fracture CAN SHE PLAY?

14 Know stress fractures Low Risk High Risk Posteromedial tibial diaphysis Metatarsal shafts Distal Fibula Medial Femoral Neck Femoral Shaft Calcaneus Anterior Tibial Diaphysis Fifth Metatarsal Base Medial Malleolus Lateral Femoral Neck Tarsal Navicular Great Toe Sesamoids World J Orthop 2017 March 18; 8(3):

15 Case #3 15 yo male basketball player with 2 days of sore throat, fever, chills, and fatigue. Has not had any sick contacts. Has a tournament this weekend PE: HR 100, Temp 100.8, RR 20, BP 110/65 Normocephalic, atraumatic Throat with exudative pharyngitis, cervical lymphadenopathy Lungs CTA bilaterally Tachycardic, RR no murmurs, rubs, or gallops Abdomen soft, NT, ND, no hepatosplenomegaly Extrem: no edema

16 Lab testing Rapid strep positive Monospot negative Treatment Amoxicillin

17 Return to Play What are the risks? Are there systemic symptoms (?fever, diarrhea) Are they contagious? Available medical personnel?

18 Above the Neck Rule Symptoms above the neck with no systemic systems (fever) Tolerate moderate activity without increase in symptoms Purcell, et al. Exercise and Febrile Illness. Pediatr Child Health, Vol 12 No

19 Case #4 15 yo male basketball player with 2 days of sore throat, fever, chills, and fatigue. Has not had any sick contacts. Has a tournament this weekend PE: HR 100, Temp 100.8, RR 20, BP 110/65 Normocephalic, atraumatic Throat with exudative pharyngitis, cervical lymphadenopathy Lungs CTA bilaterally Tachycardic, RR no murmurs, rubs, or gallops Abdomen soft, NT, ND, no hepatosplenomegaly Extrem: no edema

20 Lab testing Rapid strep negative Monospot positive VCA IgM positive VCA IgG positive Treatment Supportive

21 When can they return to play?

22 Consensus Statement for Return to Play in Mononucleosis If symptom free, may Should I image the return to light activity or spleen at time of contact 3 weeks from the onset of symptoms at diagnosis and return which time risk of splenic to play? rupture remains low Clin J Sport Med 2008;18: Spleen Length in Childhood with US: Normal Values Based on Age, Sex, and Somatometric Parameters", Radiology April :

23 Case #5 12 yo elite female gymnast presents with 4 weeks of a left hamstring strain. Initially felt a pull when doing the vault 4 weeks ago and since then has had recurrent posterior buttock and hamstring pain with any sprinting, layouts, or cartwheels. Has tried to modify workouts and push through activity but can t seem to fully recover PE: AF VSS Normal gait Normal lumbar spine exam Pain with palpation of the left ischial tuberosity Pain with resisted hamstring stressing on the left with 4-/5 strength

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25 Apophyseal Avulsion Fractures Most common in adolescents NWB until she can walk pain free, advance activity as pain allows Displaced > 15 mm, refer to surgery 27.9% 33.2% 29.7% Eberbach, H., Hohloch, L., Feucht, M. J., Konstantinidis, L., Südkamp, N. P., & Zwingmann, J. (2017). Operative versus conservative treatment of apophyseal avulsion fractures of the pelvis in the adolescents: a systematical review with meta-analysis of clinical outcome and return to sports. BMC Musculoskeletal Disorders, 18,

26 Outcome Discussed partial weight bearing, avoid all painful activity Follow up scheduled in 4 weeks to further assess Mother called 8 weeks later as pain was not improving. Patient had been doing gymnastics since diagnosis and only abstaining from vault

27 Know Growth Plate Injuries Apophysitis Apophyseal Avulsion Pain localizes to an apophysis that is worse with activity and improves with rest Most common ages 9-15 Acute injury with a sudden pop and disability during activity Most common in adolescents Wilson J, Rodenberg R. Apophysitis of the lower extremities. Contemporary Pediatrics. 2011

28 Case #6 17 yo female basketball player with history of chronic migraines (currently with a headache twice per week) anxiety and depression seen by neurology in the past on no preventative medications. Was in a game and was elbowed while going for a loose ball. She developed a headache, dizziness later that evening. In the morning when she awoke headache, dizziness had resolved but feels foggy. Referred for evaluation PE: AF VSS Normocephalic, atraumatic Immediate recall 3/3, delayed recall 3/3. Negative romberg. Cerebeller intact Vestibular ocular testing does not reproduce symptoms

29 Treatment course Once symptoms resolved, started a return to play protocol

30 Treatment course While undergoing the graduated return to play protocol develops intermittent headaches that are sometimes typical of her prior migraines but not always. These occur randomly and not always with exertion. Denies vertigo, fogginess, dizziness. Next step??

31 Use your team

32 Case #7 16 yo male wide receiver attempting to catch a pass overhead and has his right arm grabbed by the opposing team. Suffered a shoulder dislocation that was reduced on the field. Given a sling and told to follow up for futher evaluation He has never suffered a shoulder injury prior to the incident in the last game Football season is halfway completed PE: AF VSS No pain with palpation of the R shoulder girdle Pain limits abduction 90 degrees, forward flexion 90 degrees, full ER, IR back pocket No rotator cuff strength deficits Positive apprehension testing

33 Shoulder xray AP and axillary What is the next step?

34 When can he return to play? Rehabilitation (2-3 weeks) Brief Immobilization Full symmetric painless range of motion Strengthen dynamic stabilizers Supervised sport specific training

35 Should he wear a brace? One study only with no difference in recurrent instability in competitive athletes who wore a brace versus braceless peers Dickens, JF. Am J Sports Med. 2014;42:

36 What if this was his xray?

37 When he can return to play? After surgery

38 In season instability event Large Bony Bankart lesion or osseous defect of the glenoid or humeral head > 25% AP, axillary Xray and MRI Primary Soft Tissue Pathology Recurrent Instability Initial Instability Surgery Surgery Rehabilitation 2-3 weeks Immobilization Full symmetric painless ROM Strengthen dynamic stabilizers Supervised sport specific training Owens, BD. J Am Acad Orthop Surgery. 2012; 20: Surgery Return with brace No Yes Able to do sport specific skills

39 What is pediatric evidence in return to play? Consensus statements Concussion Mononucleosis

40 Strategies for return to play Diagnosis guides return to play decisions Shared decision making but remember.. When in doubt, phone a friend

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42 References Canty, G, Nilan L. Return to Play. Pediatrics in Review 2015; 36; Dickens, et al. Return to Play and recurrent instability after in-season anterior shoulder instability; a prospective multicenter study. Am J Sports Med. 2014;42: Eberbach, H., Hohloch, L., Feucht, M. J., Konstantinidis, L., Südkamp, N. P., & Zwingmann, J. (2017). Operative versus conservative treatment of apophyseal avulsion fractures of the pelvis in the adolescents: a systematical review with meta-analysis of clinical outcome and return to sports. BMC Musculoskeletal Disorders, 18, Harmon, et al. American Medical Society For Sports Medicine Position Statement: Concussion in Sport. Br J Sports Med 2013, 47, Owens BD, Dickens JF, et al. Management of mid-season traumatic anterior shoulder instability in athletes. J Am Acad Orthop Surg. 2012; 20: Purcell, et al. Exercise and Febrile Illness. Pediatr Child Health, Vol 12 No Putukian, et al. Mononucleosis and Athletic Participation: An Evidence Based Subject Review. Clin J Sport Med, Volume 18, Number 4 July 2008 Robertson, G, Wood, A. Lower Limb Stress Fractures in Sport: Optimising their Management and Outcome. World J Orthop 2017 March 18; 8(3): Wilson J, Rodenberg R. Apophysitis of the lower extremities. Contemporary Pediatrics