Care of the Patient with an Orthopaedic Sports Injury

Conflict of Interest Care of the Patient with an Orthopaedic Sports Injury Bryan Combs, MSN, FNP BC, CNL, ATC I hereby certify that, to the best of my knowledge, no aspect of my current personal or professional situation might reasonably be expected to affect significantly my views on the subject on which I am presenting other than the following: Learner Outcome Implement evidence based strategies in the care of patients who sustain sports related injuries Sports Medicine Sports medicine, also known as sport and exercise medicine, is a branch of medicine that deals with physical fitness and the treatment and prevention of injuries related to sports and exercise 1

The Sports Medicine Team Athlete The Sports Medicine Team Athlete Athletic Trainer Athletic Trainer NP/Doctor Coach NP/Doctor Coach Understand the Setting The Sideline The Training Room The Office Understand the Sport They each have specific aspects that you must know Required equipment Contact vs Non Contact How far apart are games This is critical for planning care 2

What Are the Expectations This is a difficult balance There can be a lot of voices Athlete, Coach, Parents, etc. Must keep the health of the patient as the primary goal Risk vs Reward Return To Play: Risk vs Reward What is the typical treatment plan? What is the goal of the athlete? Are they hurt or are they injured? Can they make the injury worse? Can they be protected? Where are they in the season and what is their unique situation? Not the Typical Pharmacology NSAIDs ketorolac, Ibuprofen, naproxen, and ASA Concern is ulcers and gastric bleeding Oral, Topical, Injectable Cox 2 Inhibitors celecoxib risks of heart attacks and strokes Muscle Relaxers cyclobenzaprine or methocarbamol Can be sedating Difficult in sports Corticosteroids Prednisone Often used as injection Pain relievers acetaminophen and hydrocodone The Basics H.O.P.E. With good history you will likely know what is going on before you even touch the PT Observation Swelling, Bruising, and Gait Palpate for Pain Helps isolate injury Biggest key to physical exam Evaluation ROM, Strength, and Special Tests 3

The Basics R.I.C.E. Rest Need to allow time to recover Especially for chronic or Tendonitis Ice First 72 hours Then transition to heat Always at end of day, work, or sports. Compression To decrease swelling Ace wrap or tape Elevation Above level of the heart Tendonitis Strains Shoulder Impingement Hand/Wrist Common Injuries Scaphoid Fracture Mallet Finger Knee ACL MCL Ankle Lateral Ankle Sprain High Ankle Sprain Tendonitis Tendonitis Overuse injury Location specific to activity and sport Pain worse with active motion Typically will have insidious onset May accompany change in activity or position MMT all ROM of affected area Pain with MMT Typically no pain with passive motion Use palpation to locate most significant area REST REST REST Splinting if significant When returning to activity must work slowly and in gradual manner Steroid Injections often used but proceed with caution and must educate patient no to return to early 4

Acute injury Location specific to activity and sport Pain worse with active motion but also passive motion Typically will have sudden onset Felt a pop or was hit by sniper Strains MMT all ROM of affected area Pain with MMT Typically pain with passive motion when getting to a stretch Use palpation to locate most significant area Strain RICE Once calm must improve ROM then work on strength When returning to activity must work slowly and in gradual manner Steroid Injections often used but proceed with caution and must educate patient not to return too early Question 1 Which of the following is the most important when considering treatment for tendonitis? A. Compression B. Heat C. Rest D. Acetaminophen Football Scaphoid Fracture Stingers AC Joint Separations LisFranc Sprain MCL tear High Ankle Sprain 5

Almost always acute Fall on outstretched hand Scaphoid Fracture Scaphoid Fracture Physical Exam Point tender in anatomic snuff box X-Rays of wrist with scaphoid view If pain here assume scaphoid fracture until proven otherwise Scaphoid Fracture Place in thumb spica cast or full time thumb spica splint Follow-Up in 10-14 days. X-Ray can take 10 days to show fracture This bone has poor blood supply and if not treated correctly can lead to long term problems similar to S/L Tears. (SNAC wrist) Always refer to hand surgeon if diagnosed Even not displaced will likely have some form of internal fixation Question 2 When should you schedule a follow up appointment with a patient whose x rays are normal but they have pain over their anatomic snuff box? A. 4 days B. 7 days C. 10 days D. 16 days 6

Stinger/Stinger Stinger Injury to the brachial plexus Typically due to direct contact to the shoulder or lateral neck flexion Causes a traction or compression of plexus Complaints of weakness, burning, tingling, paresthesia Spurling s test passively hyperextends and laterally flexes the patient's neck toward the involved side Increase strength in affected area and neck Work to use padding or bracing if needed This may be recurring and this should be a concern and require a thorough work up AC Joint Separation Injury to the Acromioclavicular joint of the shoulder This is the roof of the shoulder joint Connects the shoulder blade to the sternum Usually Acute Most common from fall or impact onto top of shoulder AC Joint Separation Positive piano key test Point tender over AC joint Most times there is a deformity X Ray to verify separation and no fracture Place in Figure 8 Brace This needs to be referred mostly will not require surgery, but let surgeon decide 7

Similar to ACL Common in Sports Women more susceptible due to Q Angle Usually happens while planting leg Will feel and pop and give way The knee has a valgus force Can be isolated or with ACL MCL Tear MCL Tear May have inflammation but not all the time Positive valgus stress test MCL Tear May have inflammation but not all the time Positive valgus stress test MCL Tear X Rays will likely be negative Place in hinged knee brace and on crutches if unable to walk without a limp Grade 1 Order PT Grade 2 or 3 refer to specialist 8

High Ankle Sprain Due to forced Eversion causing separation of the tibia and fibula leading to injury of the Tib Fib Ligament Very Painful Often Little Swelling Physical Exam Point tender at Tib Fib Ligament Must do weight bearing Bilateral X rays looking for syndesmosis widening High Ankle Sprain High Ankle Sprain Place in boot and make non weight bearing/on crutches Often will get steroid injection into the Tib Fib Ligament Needs referral may need surgery LisFranc Fracture/Sprain Due to driving foot into ground or having something fall on heel Is usually not a fracture but disruption of the mid foot Not as common but very debilitating 9

LisFranc Fracture/Sprain Physical Exam Pt. Tender in Mid foot Need weight bearing bilateral foot x rays Place in walking boot and non weight bearing If suspected refer ASAP May need surgery to repair Basketball Mallet Finger Jersey Finger Lateral Ankle Sprain Jones Fracture Common during sports or cleaning house Rupture of extensor tendon of finger at DIP Causes finger to drop Pt. can not extend X-Rays should be taken Mallet Finger If no fracture at distal phalanx you can splint 100% of time for 8 weeks. Finger can never bend during this time Needs to follow up with PCP or specialist If any sign of fracture then refer ASAP. It will need to be pinned to allow bone to heal. Mallet Finger 10

Question 3 Which of the following is the most appropriate treatment plan for a patient with a bony mallet finger? A. Place in full extension for 8 weeks B. Place is resting position for 6 weeks C. Schedule for follow up for 2 weeks D. Refer to surgeon for evaluation Forced extension of the DIP joint during active flexion causing rupture of flexor digitorum profundus tendon The finger will present with DIP extended Jersey Finger Jersey Finger Mainly based on history and presentation Check for flexion at DIP joint Splint in a slightly flexed or resting position Refer to hand surgeon ASAP Lateral Ankle Sprain Inversion Injury (Roll In) Most common ankle sprain Stepped of curb, rolled of someone's foot, was just jogging Many times a lot of swelling and bruising 11

Physical Assessment X ray usually negative Positive Anterior Drawer Test Point tender over Anterior Talo Fibular Ligament Lateral Ankle Sprain Physical Assessment X ray usually negative Positive Anterior Drawer Test Point tender over Anterior Talo Fibular Ligament Lateral Ankle Sprain Physical Assessment X ray usually negative Positive Anterior Drawer Test Point tender over Anterior Talo Fibular Ligament Lateral Ankle Sprain Physical Assessment X ray usually negative Positive Anterior Drawer Test Point tender over Anterior Talo Fibular Ligament Lateral Ankle Sprain 12

Lateral Ankle Sprain RICE and therapy. May need a boot to help walk until can walk with no limp Refer if no improvement in 1 2 weeks Often can return to activity with support or tape Must work on proprioception to prevent future injury Fracture of the Base of the 5 th Metatarsal where peroneus brevis attaches Common Fracture Can be a Stress FX or Acute FX Hurts on the outside of the foot Physical Exam X rays are positive for Acute but will need MRI for Stress FX Point tender on base of fifth metatarsal Jones Fracture Fracture of the Base of the 5 th Metatarsal where peroneus brevis attaches Common Fracture Can be a Stress FX or Acute FX Hurts on the outside of the foot Physical Exam X rays are positive for Acute but will need MRI for Stress FX Point tender on base of fifth metatarsal Jones Fracture RICE Place in walking boot and non weigh bearing Needs referral once diagnosed or suspected Surgeon may follow with rest or prefer surgery to fix Jones Fracture 13

Baseball/Softball Shoulder Impingement Rotator Cuff Injury Labral Tear UCL Tear Hook of the Hamate Fracture Shoulder Impingement This is an overuse injury Shoulder pain with overhead motion. Night pain with sleeping on shoulder. Pain with internal rotation. Numbness and pain radiation below the elbow are usually due to cervical spine disease. Shoulder Impingement ROM Flexion, Extension, Adduction, Abduction, Internal Rotation, External Rotation Manual Muscle Testing all ROM s Include the Empty Can Test Shoulder abducted to 90deg then adducted across chest 45deg. Then pronate arm to put thumb down as if emptying a can. Shoulder Impingement ROM Flexion, Extension, Adduction, Abduction, Internal Rotation, External Rotation Manual Muscle Testing all ROM s Include the Empty Can Test Shoulder abducted to 90deg then adducted across chest 45deg. Then pronate arm to put thumb down as if emptying a can. 14

Shoulder Impingement ROM Flexion, Extension, Adduction, Abduction, Internal Rotation, External Rotation Manual Muscle Testing all ROM s Include the Empty Can Test Shoulder abducted to 90deg then adducted across chest 45deg. Then pronate arm to put thumb down as if emptying a can. Shoulder Impingement ROM Flexion, Extension, Adduction, Abduction, Internal Rotation, External Rotation Manual Muscle Testing all ROM s Include the Empty Can Test Shoulder abducted to 90deg then adducted across chest 45deg. Then pronate arm to put thumb down as if emptying a can. Shoulder Impingement Special Tests X Rays will likely be normal Hawkins Kennedy Impingement Test Patient is sitting or standing with upper extremities relaxed Examiner grasps the patient's elbow with one hand and the patient's wrist with the other hand Examiner forward flexes the shoulder to 90 degrees and then internally rotates the patient's shoulder Will be positive if pain Shoulder Impingement Special Tests X Rays will likely be normal Hawkins Kennedy Impingement Test Patient is sitting or standing with upper extremities relaxed Examiner grasps the patient's elbow with one hand and the patient's wrist with the other hand Examiner forward flexes the shoulder to 90 degrees and then internally rotates the patient's shoulder Will be positive if pain 15

Shoulder Impingement RICE Rehab Will concentrate on rotator cuff and antiinflammatory treatments Injection You can do a corticosteroid injection to help decrease inflammation SITS Supraspinatus, Infraspinatus, Teres Minor, Subscapularis Can be acute or chronic Often associated with Labral tear History of sports or thrower A common cause of shoulder impingement syndrome after age 40. Difficulty lifting the arm with limited active range of motion. Weakness with resisted strength testing suggests full thickness tears. Rotator Cuff Injury Rotator Cuff Injury Same as Impingement Will likely diagnose with manual muscle testing Empty can test is most helpful MRI Arthrogram Shoulder must be Arthrogram Can use rehab for partial tears but I would always refer to let ortho evaluate Chronic or Acute Cartilage around glenoid to give more surface area. Think Golf Ball on golf Tee SLAP Lesion most common History of sports or thrower A common cause of shoulder impingement syndrome after age 40. Difficulty lifting the arm with limited active range of motion. Weakness with resisted strength testing suggests full thickness tears. Labrum Tear 16

Labrum Tear Same as Impingement Will likely diagnose with manual muscle testing Empty can test is most helpful MRI Arthrogram Shoulder must be Arthrogram Positive O Brien Test Can be injured with rotator cuff tear or after dislocation or subluxation RICE and therapy. If no improvement refer. Most likely will require surgery. Can use rehab for partial tears but I would always refer to let ortho evaluate Mostly Athletes throwers or people whose work stress medial elbow It is a tear of the Medial Collateral or Ulnar Ligament Tommy John s Surgery Usually develops chronically leading into an acute injury UCL Tear UCL Tear Will be point tender in medial elbow at the medial epicondyle Positive valgus stress test X Rays will be negative Always refer if suspect it. Will likely need MRI and surgery. UCL Tear Will be point tender in medial elbow at the medial epicondyle Positive valgus stress test X Rays will be negative Always refer if suspect it. Will likely need MRI and surgery. 17

Fracture Hook of Hamate Fracture Hook of Hamate Fall on outstretched hand of people that use bats or brooms Physical Exam Point tender in palm X-Rays need carpal tunnel view. Hard fracture to see. Fracture may not show for 10-14 days. Do not just assume a sprain or bruise Place thumb on pisiform and point towards web of thumb. RICE & NSAIDs If suspected or diagnosed refer but does not need to be done quickly. This will usually not heal and they just excise the fragment. Meniscus Injury ACL Tear Soccer C Shaped Cartilage in the knee Caused by stresses of the knee that pinch the meniscus between the femur and tibia Valgus, Varus, Anterior or Posterior translation Commonly associated with ACL tears Complaints of pain walking up stairs or catching or locking Meniscus Tear 18

Pain on Palpation of joint line Positive Flexion, Apley, and McMurray Tests X Rays likely normal MRI Arthrogram Meniscus Tear Pain on Palpation of joint line Positive Flexion, Apley, and McMurray Tests X Rays likely normal MRI Arthrogram Meniscus Tear Physical Assessment Pain on Palpation of joint line Positive Flexion, Apley, and McMurray Tests X Rays likely normal MRI Arthrogram Meniscus Tear Physical Assessment Pain on Palpation of joint line Positive Flexion, Apley, and McMurray Tests X Rays likely normal MRI Arthrogram Meniscus Tear 19

Meniscus Tear Will not heal on own, must be stitched or cleaned up RICE and therapy. If no improvement in 2 4 weeks refer for evaluation and possible surgery Common in Sports Women more susceptible due to Q Angle Usually happens while planting leg Will feel and pop and give way The knee has a valgus force with rotation Usually has a torn Meniscus and MCL Refer if suspected or diagnosed ACL Tear Will have palpable inflammation Positive Anterior Drawer (best test) or Lachman Test (hard to do) both tests are sliding or pulling the tibia anterior to stress the ACL. Looking for no end point ACL Tear Will have palpable inflammation Positive Anterior Drawer (best test) or Lachman Test (hard to do) both tests are sliding or pulling the tibia anterior to stress the ACL. Looking for no end point ACL Tear 20

Will have palpable inflammation Positive Anterior Drawer (best test) or Lachman Test (hard to do) both tests are sliding or pulling the tibia anterior to stress the ACL. Looking for no end point ACL Tear Will have palpable inflammation Positive Anterior Drawer (best test) or Lachman Test (hard to do) both tests are sliding or pulling the tibia anterior to stress the ACL. Looking for no end point ACL Tear ACL Tear X Rays will likely be negative Place in long leg brace and crutches MRI Arthrogram usually preference of most ortho surgeons If suspected refer Question 4 Which of the following tests would be the most beneficial when assessing a patient for a possible meniscal injury? A. McMurray s B. Lachman s C. McBurney s D. Hawkin s Kennedy 21

References Thank you! Madden, Putukian, McCary, & Young (2018), Netter's sports medicine, Philadelphia, PA: Elsevier Thompson (2016), Netter's Concise Orthopaedic Anatomy, Philadelphia, PA: Elsevier Magee (2014), Orthopedic Physical Assessment, Philadelphia, PA: Elsevier 22