SPORTS MEDICINE OVERUSE MANAGEMENT PRINCIPLES FOR

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1 SPORTS MEDICINE OVERUSE INJURIES: DIAGNOSIS AND MANAGEMENT PRINCIPLES FOR THE FAMILY PHYSICIAN DR NG CHUNG SIEN MBBS (SPORE) MSPMED (AUSTRALIA) DFD CAW SENIOR REGISTRAR CHANGI SPORTS MEDICINE CENTRE CHANGI GENERAL HOSPITAL

2 DISCLOSURE & EXTERNAL APPOINTMENTS Disclosure : none ACSM Exercise is Medicine Singapore Education Director Singapore Sports Institute Team SG Physician Singapore Rugby Union National Team Physician Football Association Singapore Medical Committee / Team Physician

3 PRESENTATION OUTLINE Overview of overuse sports injuries Common Overuse injuries Simple exercises you can teach your patients Sports Medicine treatment modalities Shoulder injection workshop

4 OVERUSE SPORTS INJURIES Overuse injuries present three distinct challenges to the clinician diagnosis, treatment and an understanding of why the injury occurred

5 Comprehensive model for injury causation. R Bahr, and T Krosshaug Br J Sports Med 2005;39: Copyright BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.

6 PATELLA FEMORAL PAIN SYNDROME

7 KEY FEATURES Most common occurs in adolescents and young adults : women > men Activity: Running Location: Anterior knee/ Retro patella Painful Squats/ Stairs / Theatre Pain Miserable Malalignment Syndrome

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10 TREATMENT Conservative Mainstay of treatment and should be done for a minimum of one year NSAIDS are more effective than steroids Operative Lateral Retinaculum Release Arthroscopic Debridement Activity modification Rehabilitation with emphasis on vastus medialis obilquus strengthening core strengthening closed chain short arc quadriceps exercises

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14 ILIOTIBIAL BAND FRICTION SYNDROME

15 Friction (or impingement) occurs near foot strike, predominantly in the foot contact phase, between the posterior edge of the iliotibial band and the underlying lateral femoral epicondyle

16 ITBFS CLINICAL ASSESSMENT Ober s Test

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21 PATELLAR TENDINOPATHY (JUMPER S KNEE)

22 PATELLAR TENDINOPATHY

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24 BLAZINA GRADING OF SEVERITY phase I pain after activity only phase II pain during and after activity phase III persistent pain with or without activities deterioration of performance

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26 EXERCISE FOR PATELLAR TENDINOPATHY

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28 PAIN IN THE ACHILLES REGION

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32 Achilles Mid Portion Tendinopathy

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34 Other options before surgery 1) ESWT 2) PRP Injections

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36 Heel drop vs Heel Raise In a study that compared these two types of exercises, 82% of patients who did the heel-drops were back to their previous activity level at the completion of treatment, whereas only 36% of those doing heel-raises achieved that outcome.

37 Achilles Enthesiopathy (Insertional Achilles tendinopathy, retrocalcaneal bursitis and Haglund s disease)

38 CALF STRETCHES

39 EXTRA CORPOREAL SHOCK WAVE THERAPY The indications for ESWT include: Plantar Fasciitis Tennis or Golfer s elbow Patellar Tendinopathy (Jumper s knee) Rotator Cuff Tendinopathy (In the shoulder) Achilles Enthesiopathy and Tendinopathy

40 PLANTAR FASCIITIS

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47 SHOULDER PAIN Clinical perspective A practical approach to shoulder pain Because there are numerous structures that can cause shoulder pain, it is helpful if the clinician can narrow the problem down into one or more of the following five categories of shoulder pain: 1. Rotator cuff musculature 2. Instability 3. Stiffness 4. AC joint 5. Referred pain

48 SHOULDER IMPINGEMENT SYNDROME Painful overhead movements/ painful arc Location anterior lateral shoulder Restricted ROM ( Forward flexion, abduction and internal rotation) Positive impingement signs

49 SPECIAL TEST

50 PRIMARY IMPINGEMENT

51 SECONDARY IMPINGEMENT

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61 FROZEN SHOULDER

62 FROZEN SHOULDER

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64 In the early stages of the disease, it may be difficult to distinguish a frozen shoulder from other causes of shoulder pain. X-rays, shoulder ultrasound scans an MRI may be ordered to exclude other causes of shoulder pain. This condition will unfortunately have to run its course. The goal of treatment is to minimise pain and discomfort during the disease process and restore full range of motion and strength by the end of its natural course. Physicians usually prescribe a course of anti-inflammatory medication for pain relief. Forceful manipulation should be avoided as this may worsen the symptoms. Intra-articular cortisone injection to the shoulder joint may help improve joint stiffness and reduce symptoms of pain Hydrodilation, a medical procedure in which sterile fluid is injected into the shoulder joint under local anesthesia, may be required in severely symptomatic subjects.this helps to loosen the joint adhesions

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69 TENNIS ELBOW

70 TENNIS ELBOW

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73 TENNIS ELBOW

74 TENNIS ELBOW

75 GOLFER S ELBOW

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80 FAQ When to refer? Who to refer to? Sports medicine Orthopaedics Allied health services (Physiotherapist, Podiatry, Sports Trainers, Dietician)

81 SERVICES AVAILABLE AT CHANGI SPORTS MEDICINE CENTRE Sports Injuries Consultation by Sports Med & Sports Ortho Specialist Bedside high resolution ultrasound diagnostic scans Advance MRI facilities Ultrasound guided therapeutic procedures (feswt, RSWT, PRP /HA injections)

82 SUPERVISED SPORTS SPECIFIC PHYSIOTHERAPIST LEAD REHABILITATION Visit CSMC

83 KEY CONCEPTS Making the correct patho-anatomic diagnosis Identify underlying causes (Extrinsic and Intrinsic risk factors) Rest and NSAIDS alone do not heal Rehabilitation exercises is key to healing

84 ILLUSTRATION CREDITS The illustrations used in this presentation are adapted from the following publications: Exercise Prescription Guide by Dr Benedict Tan, Dr Ng Chung Sien and Dr Ivy Lim Clinical Sports Medicine (4 th Edition) by Peter Bruckner and Karim Khan

85 THANK YOU! Stay back though Shoulder injection workshop after this.