Patellar tendonitis aka jumpers knee

Activity related knee pain due to degenerative, micro injury rather than an inflammatory process

Up to 20% in jumping athletes

Anterior knee pain during or after activity

Bassett Sign:
       a)  Tenderness to palpation with knee in full extension (patellar tendon relaxed)
       b) No tenderness with knee in flexion  (patellar tendon tight)
 

Return to Play After Infectious Mononucleosis (IM)

-Long incubation period make it difficult to determine source or onset

Presentation often atypical with nothing more than fatigue, decreased energy or decreased athletic performance.

DDX: Herpes simplex, HIV, CMV, toxo and strep (simultaneous infection may be seen in up to 30%)

Classic 3 to 5 day prodromal period (malaise, fatigue, anorexia)

Symptoms then progress into the classic “triad” of IM

                Fever, pharyngitis, lymphadenopathy (esp. posterior cervical nodes)

May also have posterior palantine petechiae ( of cases), jaundice, exudative pharyngitis, rash and splenomegaly)

Rash (10% to 40%), transient, generalized maculopapular, petechial or urticarial)

                Most commonly seen in patients treated with PCN antibiotics

Splenomegaly is an important complication in the athletic population

Mononucleosis makes the spleen susceptible to rupture (traumatic or spontaneous)

                - Lymphocytic proliferation enlarges the spleen beyond protection from the ribs

                - Physical examination has been shown to be unreliable for determining splenomegaly

                - Highest risk is in the first 21 days (rare after 28 days)

Ultrasound is the modality of choice

                -Splenomegaly peaks at 2 to 3 weeks and resolves in the majority between 4 to 6 weeks

Return to play is generally allowed after 4 weeks from diagnosis in the absence of splenomegaly and resolution of symptoms.

Cervical Cord Neuropraxia (CCN)

A concussion of the spinal cord as a result of an on-field collision.

A transient motor and/or sensory disturbance, lasting less than 24 hours.

A distinct and separate entity from spinal cord injury resulting in quadriplegia

Incidence 7.3 per 10,000 athletes

Approx. 50% of players experiencing CCN who return to play, have a second episode

The risk of this second episode is inversely proportional to the size of the cervical bony canal

Athletes with narrow canal diameter are more likely to have a 2nd episode

               Those with normal canal diameter (14 mm on MRI) have a 5% risk

               Those with a narrow canal (9 mm or less)) have a greater than 50% risk.

Whether repeat episodes lead to permanent spinal cord injury is unknown

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Football helmets

A review of head and neck injuries from football from 1959 to 1963 found the rates of intracranial hemorrhage /intracranial death were 2-3X higher than the rates of cervical spine fracture/dislocation or cervical quadriplegia. In contrast, a study of football injuries from 1971 to 1975, revealed a dramatic reversal in rates. Cervical injuries now exceeded the rate of ICH by 2-4X.

                A 66% reduction in ICH

                A 42% reduction in craniocerebral deaths            

                A 204% increase in cervical spine fractures and dislocations

The shift was attributed to the modern football helmet, whose superior protection promoted “spearing” (headfirst tackling technique). Spearing involves hitting with the crown of the helmet leading to axial loading of the spine. Spearing accounted for 52% of the quadriplegia injuries from 1971 to 1975. Research by Joesph Torg, M.D., resulted in rule changes that led to an immediate 50% reduction in quadriplegia in NCAA football.

As a parent, coach or team physician, teach and enforce proper form and protect our young athletes.

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Happy Memorial Day! With all the recent attention in the news about swimming and drowning I thought I would share this article

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Risk Modifiers for Concussion and Prolonged Recovery

A history of prior concussion is a risk factor for future concussion (>2x risk).

For individual sports, boxing has the highest risk.

For team sports, football, ice hockey and rugby have the highest risk.

Women’s soccer confers the highest risk for female athletes.

Younger age confers increased risk.

Female sex confers higher risk when comparing similar sports with similar rules.

Those with migraine headaches may be at increased risk.

Risk of prolonged concussion

Most athletes have symptom resolution within one week

Post traumatic amnesia (both retrograde and anterograde) predict increased number and longer duration of symptoms.

Younger age also predicts pronged recovery.

Other studies have found associations with headache lasting greater than 60 hours, fatigue, “fogginess,” or greater than 3 symptoms at initial presentation. Cognitive studies have identified deficits in visual memory and process speed as predictors of prolonged recovery. 

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Acetaminophen spent much of 2013 being chased by paparazzi and sharing magazine covers with Miley Cyrus. What a fall from stardom after becoming known as the pain reliever “hospitals use most,” and the one, “recommended by pediatricians.” Slogans we know well based on $100 million/year spent on advertising.

Approximately 150 patients a year die from unintentional acetaminophen poisoning averaged over the past 10 years. From 2001 to 2010, annual acetaminophen-related deaths amounted to about twice the number attributed to all other over-the-counter pain relievers combined, 

The FDA sets the maximum recommended daily dose of acetaminophen at 4 grams, or eight extra strength acetaminophen tablets.

Ingestion of 150 mg/kg or approximately 10g for a 70 mg individual reaches the toxic threshold for a single ingestion. The toxic threshold decreases in cases of chronic ingestion.

Patients who “unintentionally” overdose have been found to take just over 8g per day (almost double the recommended maximum).  This is unlikely due to taking one extra 325mg tablet once or twice.

Before we all go on a mad NSAID prescribing binge, let's all be aware of the dangers, educate our patients and allow Acetaminophen to walk the red carpet again.

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Ankle Syndesmosis Injuries are also called high ankle sprains as they involve trauma to the ligaments above the ankle joint

Most ankle sprains are lateral ankle sprains. High ankle sprains are relatively uncommon.

Usual mechanism: External rotation injuries

Exam: Tenderness at the syndesmosis and compression of the tib/fib at the mid calf level causing syndesmosis pain (squeeze test)

Median recovery time is almost 4 times as long as a lateral ankle sprain 62days vs. 15days

Emergency department care is similar tto that of other ankle sprains but the added benefit of patient education and advice may improve overall care and follow-up.

Herpes Gladiatorum in Wrestlers

HSV causes non genital cutaneous infections primarily in wrestlers, commonly called herpes gladiatorum (HG)

Annual incidence in NCAA wrestlers is 20% to 40%

Most common cutaneous infection leading to lost practice time (40.5% of all infections)

Transmission is skin to skin.

Incubation period is 4 to 7 days from exposure. Healing usually occurs within 10 days after the initial lesion (without scaring).

Appearance: Numerous grouped uncomfortable (painful) vesicles/pustules on an erythematous base…evolve into moist ulcerations, followed by crusted plaques.  Lesions typically get abraded during competition therefore may have an atypical appearance and may be mistaken for other infections such as staph. Distribution typically more diffuse than typical HSV infections. Occurs on body surfaces areas that typically come into contract with opponents (face, head, neck, ears, upper extremities).  Lesion location typically on side of patient’s handedness. Recurrences occur at location of initial outbreak, a useful diagnostic aid.

Perform a thorough examination as ocular involvement was seen in 8%  of high school wrestlers  in one HG outbreak.

Typical treatment for primary infection is Valacyclovir 1g PO b.i.d. for 7 days. This is best started within 24h of symptom onset.

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The clinical examination is often unreliable in ruling out septic arthritis in the ED.

 Diagnostic arthrocentesis is often performed.

Traditional teaching involved very high WBC count thresholds as part of diagnosis.

In one 2009 study, synovial leukocyte counts in cases of MRSA were often less than 25,000 cells/uL

Have a low threshold for empiric antibioitics even in the face of low WBC counts (and incredulous consultants)

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Overtraining syndrome

A maladaptive response to excessive exercise without adequate functional rest

-Results in disturbances of multiple body systems (neurologic, endocrinologic, immunologic and psychologic).

- May be caused by systemic inflammation and resultant neurohormonal changes
            - Multiple hypotheses exist

-Symptoms

Parasympathetic alterations: fatigue, depression, bradycardia

Sympathetic alterations: insomnia, irritability, agitation, tachycardia, hypertension, restlessness

Other: anorexia, weight loss, poor concentration, anxiety

Usual presentation is prolonged underperformance despite adequate rest and recovery (weeks to months).

Pelllegrini-Stieda lesion

Ossified post-traumatic lesions at the MCL adjacent to the femoral attachment site of the medial femoral condyle.

Mechanism is likely from an avulsion injury that subsequently calcifies after the initial trauma.

Often an incidental finding on plain films.

If symptomatic, refer to ortho as an outpatient

If not symptomatic, no treatment is indicated

http://images.radiopaedia.org/images/30076/b62e61e83241e30f2da693901edcdc_gallery.jpg

http://www.imageinterpretation.co.uk/images/knee/PELLEGRINI%20STIEDA2.jpg

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No single feature of the history of physical examination reliably rules out ostemyelitis

Aids in making the diagnosis include:

An ulcer area larger than 2 cm² (LR 7.2),

A positive probe to bone test (LR 6.4),

An ESR greater than 70 mm/h (LR 11)

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Treating knee osteoarthritis - from the American College of Rheumatology 

Exercise whether it be aquatic, aerobic (land -based) or resistance can decrease pain and improve functional capacity. Exercise should be performed 3 to 5 times a week. Effects are usually noted after 3 to 6 months.

Weight loss of 5% or greater body weight is associated with a small improvement in pain and physical function. The main benefit of weight loss has more to do to effects on co-morbid conditions.

Walking aids: A single crutch or cane should be held on the side contralateral to the affected knee and should be advanced with the affected limb when walking to reduce the load on the affected joint. 

Cane sizing: The distance from the floor to the patient's greater trochanter (brings the elbow to 15º to 20º of flexion.

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Unexplained respiratory symptoms during exercise are often incorrectly considered secondary to exercise induced asthma/bronchospasm.

An important diagnosis on the differential should be exercise-induced laryngeal obstruction (EILO).

Of 91 athletes referred for asthma workup, 35% had EILO.

The presence of inspiratory symptoms did not differentiate athletes with and without EILO.

61% of athletes with EILO used regular asthma medication at referral.

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Cauda equina syndrome results from compression of multiple lumbar and sacral nerve roots

Causes: Central disc herniation, spinal epidural abscess, malignancy, trauma, hematoma.

Consider this entity in those with back pain and radiculopathy at multiple spinal levels

Urinary retention occurs in >90% of patients

Saddle anesthesia occurs in 75%

Decreased rectal sphincter tone occurs in 60 to 80%

A post void residual volume <100 mL makes this entity very unlikely

 Lateral hip pain

 Findings of weakness and/or pain while testing hip abduction may point to gluteus medius muscle dysfunction with associated with greater trochanteric pain syndrome.

The Trendelenburg test may help. The patient stands on the affected leg. A negative test result occurs when the pelvis rises on the opposite side. A positive test result occurs when the pelvis on the opposite side drops and indicates a weak or painful gluteus medius muscle.

http://www.youtube.com/watch?v=TY-G4ErruUA
 

Prior fracture represents the strongest predictor of stress fracture in both sexes

For girls:  Low body mass index, (<19), late menarche (age 15 or older), previous participation in gymnastics and dance.

For boys: increased number of seasons.

Participation in basketball appears protective in boys.

This may represent a modifiable risk factor for stress fractures.

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