Hot Topics in Sports Medicine 2015 - UCSF CME. Senter- Hot topics s… · 22.05.2015 · Hot Topics in Sports Medicine 2015 •Sports concussion –Diagnosis –Treatment •Knee

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Hot Topics in Sports Medicine 2015

Carlin Senter M.D.

UCSF Internal Medicine and Orthopaedics

UCSF Advances in Internal Medicine

Hot Topics in Sports Medicine 2015

• Sports concussion – Diagnosis

– Treatment

• Knee pain due to osteoarthritis + meniscus tear – Exam

– Treatment evidence

• Rotator cuff tears – Physical examination evidence

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Concussions are common

US military and traumatic brain injury

• 320,000 blast-related TBIs from wars in Iraq and Afghanistan (MacDonald CL et al. Detection of Blast-Related Traumatic Brain

Injury in US Military Personnel, New England Journal of Medicine 2011.)

• mTBI accounts for 80-90% of TBI in civilian and military populations (Levin HS and Diaz-Arrastia RR. Lancet Neurol

2015; 14: 506-17.)

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Concussion numbers increasing

Marin JR et al. Trends in visits for traumatic brain injury to emergency

departments in the United States. JAMA. 2014 May 14;311(18):1917-9.

Concussion legislation

• California: Education Code 49475 (effective 1/2012)

1. Student athletes and guardians sign a concussion information form yearly

2. Athlete suspected of having concussion removed at time of injury for the rest of the day

3. Athlete can return only after cleared by healthcare professional trained in evaluation and management of concussion

http://fuerzadesign.com/wp-content/uploads/2014/10/thumbnail-United-States.jpg

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Case #1

• 40 y/o woman presents to your office for ER follow-up two days after bike accident.

• Slid out while crossing streetcar tracks on wet city streets.

• No loss of consciousness. • Taken by ambulance to ER. • Had trauma work-up including head CT (-). • Has headache, fatigue, dizziness, light sensitivity.

Trouble staying focused at work, sleeping more than usual.

• Normal neck and neurologic exam.

Concussion definition

• Type of mild traumatic brain injury

• Blow to head, neck, body force to head

• Rapid onset of neurologic impairment

• Symptoms usually resolve in weeks, spontaneously, but in some cases can be prolonged.

• May or may not include loss of consciousness.

• CT and MRI studies are normal

Adapted from 4th International Conference on

Concussion in Sport (2012). Br J Sport Med.

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Physical

Cognitive

Emotional

Sleep

Concussion symptoms

http://www.cdc.gov/ncipc/tbi/Facts_for_Physicians_booklet.pdf. Accessed Nov. 9, 2008.

Clinic concussion evaluation

• History of injury

• PMHx ADHD, anxiety, depression, head injury

• Clinical status: improving or worsening since time of injury?

• Neck and neurological exam

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• Age > 60 • GCS < 14 initially or < 15

two hours post injury • Vomiting more than once • Seizure • LOC • Focal neuro deficit • Suspected skull fx • Severe headache

• Decreased alertness after initially lucid

• High velocity injury (hit by car, fall from height)

• Comorbid illness (cirrhosis, diabetes, immunosuppression)

• Pregnancy • Anticoagulants

Adapted from Levin HS and Diaz-Arrastia RR. Lancet Neurol 2015; 14: 506-17,

using NICE 2014 and 2008 American College of Emergency Physicians/US CDC

policy statement.

How severe is my concussion?

• Concussion grading is retrospective – Historically concussions were graded on the

sideline based on amnesia and LOC at time of

injury. – American Academy of Neurology, 1997

– Cantu, 2001

– Studies have shown these factors not to be predictive

of recovery.

• Only when the athlete recovers can you tell how severe the concussion was

http://thehoopla.wpengine.netdna-cdn.com/wp-

content/uploads/2012/10/rage-meter-1.jpg

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Symptom resolution

• Athletes become asymptomatic in 1-2 weeks (Williams RM et al. Sports Med. 2015 Mar 28.)

• Recovery in athletes may be faster than in others (Levin HS and Diaz-Arrastia RR. Lancet Neurol 2015; 14: 506-17.)

• Pre-existing neuropsychiatric disorder associated with symptoms > 3 months (Levin HS and Diaz-Arrastia RR.

Lancet Neurol 2015; 14: 506-17.)

Case #1

• 40 y/o woman presents to your office for ER follow-up two days after bike accident.

• Slid out while crossing streetcar tracks on wet city streets.

• No loss of consciousness. • Taken by ambulance to ER. • Had trauma work-up including head CT (-). • Has headache, fatigue, dizziness, light sensitivity.

Trouble staying focused at work, sleeping more than usual.

• Normal neck and neurologic exam.

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How would you treat this patient?

1. Order urgent head CT to rule out subtle post traumatic bleed, return to clinic after CT.

2. Rest from work and biking, return to clinic 1 week.

3. Return to work but rest from biking, return to clinic in a month.

4. Return to work and biking.

Concussion treatment

• Cognitive rest

• Physical rest

• Medication – Tylenol

– Ibuprofen after first 72 hours

• No driving

• No alcohol

• Education

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Return to school/work progression

No school.

OK to do light reading, little bit TV, drawing, cooking as long as doesn’t worsen symptoms.

15 min cognitive activity at a time.

Return to full day of school.

http://www.chop.edu/service/concussion-care-

for-kids/returning-to-school.html

30 min schoolwork at a time until can do 1-2 hours.

Return to ½ day of school.

Physical rest

• Evidence sparse on benefit of rest

• Management largely guided by expert opinion

• No same-day return to play

• Once concussion symptoms have resolved gradually return to play

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Return to play progression

Light aerobic activity

Sport specific activity

Game play

Non-contact training

Full contact practice

Clinician clearance

Asymptomatic

2nd International Conference on Concussion in

Sport (2004). 2005 Br J Sport Med 39:196.

Concussion statement 2012

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Case #2

• 55 y/o man with medial-sided pain and swelling of the R knee for 6 weeks.

• No locking, no instability

• Exam: effusion, tender medial joint line and above/below medial joint line, (+) medial knee irritation with medial McMurray, (+) medial pain with squat and Thessaly, no ligamentous laxity

• He brings with him x-rays and MRI for your review

EFFUSION

Area of tenderness

http://www.ski-injury.com/kneeanat.gif, Accessed 10/04/05. Accessed 10/4/05

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Meniscus: McMurray

Sensitivity medial 65%, Specificity medial 93% Magee, DJ. Orthopaedic Physical Assessment, 5th ed. 2008.

Meniscus: Thessaly

Video used with permission from Anthony Luke, MD.

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Meniscus: squat

Radiograph

3 views for knee pain – Weight bearing

flexed PA (aka notch view)

– Lateral of affected side

– Sunrise or merchant view

http://nurse-practitioners-and-physician-

assistants.advanceweb.com/Features/Artic

les/Knee-Osteoarthritis.aspx

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MRI - report

• Menisci: complex degenerative tearing of the medial meniscus posterior horn and body.

• Cruciate ligaments: intact

• MCL/LCL: intact

• Extensor mechanism: intact

• Cartilage and bone: moderate-grade cartilage loss over the medial femoral condyle and medial tibial plateau

Diagnosis?

A. Medial meniscus tear

B. ACL tear

C. Moderate medial compartment osteoarthritis

D. Patellar dislocation

E. Septic arthritis

F. Medial meniscus tear and moderate medial compartment osteoarthritis

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Initial treatment?

A. Refer for arthroscopic debridement of meniscus tear and lavage

B. Nonoperative knee OA program

C. Refer for total knee arthroplasty

• 188 patients followed x 2 years • Primary endpoint WOMAC score (knee pain + fxn) • Avg age 60, 2/3 female, BMI 31 • Excluded bucket handle meniscus and severe

varus or valgus alignment

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Interventions

• Control – PT: 1 hour/week x 12

weeks

– Home ex program 2x/day

– Instruction on ADLS

– Self management arthritis education reading + videotape

– Medications (APAP, NSAIDs, hyaluronic acid injections)

• Arthroscopic surgery – Irrigation with saline

– 1 or more of the following: • Debridement or excision

of degenerative meniscus tears

• Removal loose bodies, chondral flaps, bone spurs

– Medical and physical therapy like controls

Kirkley et al. A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the

Knee, NEJM, 2008.

Results

Kirkley et al. A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the

Knee, NEJM, 2008.

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Katz JN et al. Surgery versus physical therapy for a meniscal tear and

osteoarthritis. N Engl J Med. 2013 May 2;368(18):1675-84.

Surgery vs PT for meniscal tear and OA

• Multicenter RCT • 351 patients with meniscus tear + OA • Meniscus sxs (clicking, popping, catching, giving

way, joint line pain, pain with twisting) • Avg. age 60 years • 50% men, 50% women • Primary outcome = change in WOMAC physical-

function score between groups at 6 mo

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Interventions

• Control (PT)

– Usually 6 weeks

– 3-stage program

• APAP, NSAIDs, intraarticular steroid injections as needed

• Arthroscopic partial meniscectomy (APM)

– Trim damaged meniscus back to stable rim

– Remove loose cartilage and bone

• PT protocol

• APAP, NSAIDs, intraarticular steroid injections as needed



Results



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Results



Conclusions

• 30% crossed over from PT to APM at 6mo

– These people had WOMACs that didn’t improve until crossover

• No sig difference in adverse events

• PT and APM are reasonable options with similar outcomes for these patients (with allowed cross over if not achieving relief with PT)

• Starting with conservative approach is reasonable



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Osteoarthritis with meniscus tear

• Meniscus tear is part of the natural history of osteoarthritis • Treat as osteoarthritis initially • Imaging: Start with xray, MRI if exam c/w meniscus tear and

not improving with PT • Consider arthroscopic meniscus surgery if PT, medications,

injections not helping or if patient prefers surgical treatment

http://www.weddingbee.com/2009/07/20/rock-paper-scissors-shoot/

Caveats: Who to Refer

• Younger patients

• Bucket handle meniscus tears

– Knee locked due to meniscus blocking joint movement

• Mechanical symptoms: locking, catching

• Failure of nonoperative knee OA treatment

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3 excellent articles for Non-op knee OA treatment

• Hochberg MC et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken). 2012 Apr;64(4):465-74.

• McAlindon TE et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. 2014 Mar;22(3):363-88.

• Bannuru RR et al. Comparative effectiveness of pharmacologic interventions for knee osteoarthritis: a systematic review and network meta-analysis. Ann Intern Med. 2015 Jan 6;162(1):46-54.

Case #3

57 y/o RHD man presents with R shoulder pain that started after he slipped and fell 3 months ago. Pain at R deltoid. He tried physical therapy without benefit. Waking at night from sleep due to pain.

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Differential diagnosis?

Rotator cuff disease in primary care

• The 3rd most frequent musculoskeletal reason patients present to the office

• The most common cause of shoulder pain in patients in the US primary care settings

Whittle S, Buchbinder R. In the clinic. Rotator cuff disease. Ann Intern Med.

2015 Jan 6;162(1):ITC1-15.

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What is rotator cuff disease?

• Impingement

• Tendinitis/tendinopathy

• Partial thickness tear

• Full thickness tear

Rotator cuff disease treatment

Most do well with conservative treatment

• Impingement

• Tendinitis, tendinopathy

• Partial tear

• Full thickness tear Consider ortho referral.

PT +/- Injection

+/- Medication

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Rotator cuff surgery outcomes

Better if (acute) full thickness rotator cuff tears fixed earlier than later

• Smaller tear size associated with better outcome (Cofield RH et al. Surgical repair of chronic rotator cuff tears. JBJS

2001.)

• Less fatty infiltration and muscle atrophy associated with better outcome (Gladstone JN et al. Fatty

infiltration and atrophy of the rotator cuff do not improve after rotator cuff repair and correlate with poor functional outcome. AJSM 2007.)

Shoulder: diagnosis driven exam

Active ROM

Decreased Normal

Passive ROM

Normal

Decreased

Xray Frozen shoulder

Normal

GH joint OA

Abnormal

Rotator cuff tear Other rotator cuff dz

Labral tear Biceps tendinitis

AC joint OA

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Physical exam maneuvers that increase likelihood of rotator cuff disease

1. Painful arc

2. Drop arm test

Pain test: Painful arc

JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug

2013.

If painful, positive

LR 3.7 for RCD.

If not painful,

negative LR 0.36

for RCD.

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Pain/strength test: Drop arm test

JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug

2013.

Positive LR 3.3,

negative LR

0.82 for rotator

cuff disease.

Physical exam maneuvers that increase likelihood of

full thickness rotator cuff tear

1. External rotation lag test

2. Internal rotation lag test

https://www.healthbase.com/hb/images/cm

/procedures/orthopedics/rotator_cuff_tear.j

pg

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Strength test: External rotation lag test

Positive LR 7.2,

Negative LR 0.57

for full thickness

rotator cuff tear

JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013.

Pain & Strength test: Subscapularis = internal rotation lag

test aka ‘lift off’

JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013.

Positive LR

5.6, negative

LR 0.04 for

full

thickness

rotator cuff

tear

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Case #3

57 y/o RHD man presents with R shoulder pain that started after he fell 3 months ago. Pain at R deltoid. He tried physical therapy without benefit. Waking at night from sleep due to pain.

Exam: no atrophy. Nontender biceps, AC Joint. AROM symmetric bilaterally (forward flexion, external + internal rotation, abduction).

(+) painful arc, (+) drop arm, (+) ER lag, (+) IR lag

Diagnosis

A. Adhesive capsulitis

B. Rotator cuff tear

C. Impingement syndrome

D. Glenohumeral joint osteoarthritis

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Shoulder: diagnosis driven exam

Active ROM

Decreased Normal

Passive ROM

Normal

Decreased

Xray Frozen shoulder

Normal

GH joint OA

Abnormal

Rotator cuff tear Other rotator cuff dz

Labral tear Biceps tendinitis

AC joint OA

Treatment

A. Refer for surgical consult

B. Repeat trial of physical therapy, f/u 3 months.

C. Give NSAIDs and activity modification, f/u 3 months

D. Give subacromial injection, f/u 3 months

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3 excellent shoulder articles

1. O'Kane JW, Toresdahl BG. The evidenced-based shoulder evaluation. Curr Sports Med Rep. 2014 Sep-Oct;13(5):307-13.

2. Hermans J et al. Does this patient with shoulder pain have rotator cuff disease?: The Rational Clinical Examination systematic review. JAMA. 2013 Aug 28;310(8):837-47.

3. Whittle S, Buchbinder R. In the clinic. Rotator cuff disease. Ann Intern Med. 2015 Jan 6;162(1):ITC1-15.

Thank you!

Carlin Senter, M.D.

Primary Care Sports Medicine

UCSF Internal Medicine and Orthopaedics

Hot Topics in Sports Medicine 2015 - UCSF CME. Senter- Hot topics s… · 22.05.2015 · Hot Topics in Sports Medicine 2015 •Sports concussion –Diagnosis –Treatment •Knee

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