Resolving the Top Three Boot Camp Injuries Ryan Matthiesen DO
About Me Oklahoma State College of Osteopathic Medicine Family Medicine Residency Plaza Medical Center Sports Medicine Fellowship Texas Tech University Team Physician University of North Texas
Boot Camp Common participants wide range High level athletes Getting back in shape Sedentary exercising for the first time
Boot Camp Type of exercises variety Body weight exercises Running/sprinting HIIT
Boot Camp Risk factors for injury Supervision varies by location Lack of prior experience/poor form People pushing themselves to hard Improper warm-up/cool down
Boot Camp Most common areas injured Shoulder Knee Ankle Back
Case 1 40 yo female, BMI 40, mother of 2, works a desk job, little activity Started a boot camp through church 3 weeks ago, started having right knee pain during the second week. No injury/fall, no history of knee pain
Case 1 PMH: HTN, obesity Pertinent history: denies swelling, clicking or popping. Pain is worst getting up from sitting or going up stairs
Case 1 PE: no effusion, -lachmans/anterior drawer/mcmurrays, no pain with varus/valgus pressure, no TTP along joint line, +TTP lateral patella, + patellar grind, + patellar crepitus DDx: patellar tendinitis, IT band syndrome, OA, patellar subluxation, PFS
Workup? Case 1 X-ray: patella alta (high riding patella) and mild lateral patellar tracking MRI? Not necessary
Case 1 Diagnosis? PFS (Patellofemoral syndrome) Abnormal contact of patella w/ femur during glide MCC knee pain overall Hints: location of pain/ttp, x-ray findings, recent increase activity after none
Case 1 Treatment: PT focusing on VMO strengthening and hamstring flexibility, activity modification Return to activity: slow increase in activity after finishing directed PT, with pain as guide for speed of return and activities to avoid
Case 2 32 yo male, former collegiate football player, BMI 34, works manual job in a warehouse Has been trying to get back into shape with local gym. In an ATC class, during a sharp turn during sprints felt a sudden pop and medial knee pain
Case 2 Pertinent history: minimal swelling first 24 hours with slow increase to moderate effusion. + popping/clicking. Reports knee feels weird, like its floating.
Case 2 PE: moderate effusion, +TTP medial joint line, + pop and pain mcmurrays w/ medial compression, -lachmans/drawer, mild pain but no gapping w/ valgus pressure DDx: MCl sprain/tear, ACL tear, meniscal tear, PFS
Workup? Case 2 X-ray: moderate effusion, otherwise normal MRI: 2 options, wait and see how much improvement w/ 2 weeks of rest vs. go straight to MRI. With age and desired level of activity along w/ + PE, MRI early in course is acceptable option
Case 2 Diagnosis? Medial meniscal injury with grade 1 MCL sprain Hints: + mechanical signs, + effusion, method of injury
Case 2 Treatment: based on location (medial) and severity, surgery would likely yield the best outcomes vs. conservative A large number of patients will have similar outcomes in pain and dysfunction with conservative treatment at 1 year after injury Return to activity: Surgical: 4-6/8-12 weeks based on type of surgery Conservative: 4-6 weeks based on pain and mechanical symptoms
Case 1&2 Key takeaways of knee Early evaluation can be difficult due to pain/swelling Absence or presence of effusion indicates pathology within the joint Absence or presence of mechanical symptoms When to go for an MRI
Case 1&2 Common knee injuries IT band syndrome (MCC in runners) ACL tear (early onset effusion) Patellar/quad tendinitis (pain w/ jumping/squatting)
Case 3 49 yo right handed male c/o 3 weeks worsening right shoulder pain after falling while running and catching himself with right hand. Felt a sharp pop when it happened.
Case 3 PMH: DM 2, HLD, HTN Pertinent history: Pain worse w/ raising arm above shoulder and doing pushups, feels occasional popping. No radiation of pain. Has not done any exercise for last 3 weeks
Case 3 PE: TTP under lateral acromion, + pain and weakness w/ Jobes (empty can), decreased IR and abduction due to pain, + pain w/ obriens, + hawkins impingement testing, + pain w/ speeds DDx: Proximal biceps tendinitis, labral tear, impingement syndrome, glenohumeral OA, rotator cuff tear
Case 3 Workup? X-ray: Type 3 acromion, sub acromial spurring, high riding humeral head MRI? No improvement with rest, + weakness, MRI would be useful in diagnosis X-ray findings of sub acromial spurring and high riding humeral head concerning for rotator cuff tear
Case 3 Diagnosis? Rotator cuff tear (supraspinatus) MRI showed 75% thickness posterior tear supraspinatus, labrum intact, mild biceps tendinitis Tx: >50% tear will likely require operative fixation, can also perform sub acromial decompression to reduce risk of repeat
Case 3 Key takeaways from the shoulder Weakness during exam is concerning for tear vs. tendonitis (just pain) RF for rotator cuff pathology: type 2/3 acromion, sub acromial spurring, poor form during pressing exercises puts increased pressure and strain on supraspinatus (elbows >60 degrees IR)
Case 3 Common shoulder injuries Sub acromial bursitis (TTP, minimal pain w/ testing or movement) Rotator cuff tendinitis (pain, no weakness) AC/GH arthritis Biceps tendonitis
Case 4 28yo female boot camp instructor, leading a run through the woods tripped on a tree root and sustained an inversion injury yesterday She had significant generalized ankle swelling and had difficulty walking on it directly after the injury. Former soccer athlete, hx multiple ankle sprains
Case 4 PMH: none Pertinent history: patient performed RICE overnight with little change, still has pain w/ walking.
Case 4 PE: large effusion lateral ankle, reduced ROM. +TTP laterally over ATFL, +TTP over base of 5 th metatarsal, - drawer, able to walk across room w/ slight limp. DDx: lateral ankle sprain, peroneal tendinitis, fibular fracture, 5 th MT fracture Workup?
Case 4 Ottawa Ankle Rules Bony TTP Tip medial malleolus or posterior edge distal 6cm tibia Tip lateral malleolus or posterior edge distal 6cm fibula Navicular Base 5 th metatarsal Inability to bear weight directly after injury and in ER for 4 steps
X-ray: Case 4
Case 4 Diagnosis? Non-displaced 5 th MT fracture Treatment: fracture walker, weight bearing, repeat x-ray in 3-4 weeks
Case 4 Key takeaways from the ankle Bony tenderness key in determining need for imaging Stabilizing with bracing can improve comfort and reduce healing time in soft tissue injuries and fractures
Case 4 Common ankle injuries Achilles tendinitis Ankle sprain Medial/lateral malleolar fracture Navicular avulsion fracture Base 5 th MT fracture (avulsion, Jones, mid-shaft) Peroneal tendonitis Plantar fasciitis
Boot Camp Questions? Thank you