Category: Orthopedics
Keywords: Concussion, active recovery, exercise (PubMed Search)
Posted: 10/5/2021 by Brian Corwell, MD
(Updated: 12/12/2024)
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The Role of Active Rehabilitation in Concussion Management: A Systematic Review and Meta-analysis
Concussions make up 70% to 90% of all traumatic brain injuries
During the recovery process, prolonged rest has been shown to slow recovery and precipitate secondary symptoms of fatigue, reactive depression, anxiety and physical deconditioning.
As a result, a gradual increase in low-level activities has been encouraged after 24-48 h of rest.
23 articles for a total of 2547 concussed individuals, 49% female, both kids and adults. Included both sport related and non-sport related concussion.
None of the studies reported any adverse events in symptomatic participants after subthreshold exacerbation aerobic exercise.
Duration ranged from 15-20 minutes per session or until symptom exacerbation.
Subthreshold activity generally targeted 80% of max heart rate achieved during a graded symptom threshold test.
Every study showed improved concussion symptom scores with a physical activity intervention.
Most common treatment duration was 6 weeks (Range 1-12 wk)
Best outcomes if initiated with 2-3 weeks after injury but intervention beneficial in chronic phases of recovery as well.
The intervention of physical activity decreases post concussion symptom scores and the overall effect across studies was large and positive.
Optimal intensity, duration and time to initiation of exercise intervention needs further investigation.
Exercise effect is likely multifactorial including:
One of the best effects I have seen in treating these patients is that active exercise allows a proactive approach to patient recovery. Patients become less focused on every minor symptom or irregularity.
Carter KM, et al. The Role of Active Rehabilitation in Concussion Management: A Systematic Review and Meta-analysis. Med Sci Sports Exerc. 2021 Sep 1;53(9):1835-1845.
Category: Orthopedics
Keywords: heat stroke, marathon (PubMed Search)
Posted: 9/14/2021 by Brian Corwell, MD
(Updated: 12/12/2024)
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Exertional Heat Stroke at the Boston Marathon
Study goal: To assess for possible associations between exertional heat stroke (EHS) and sex, age, prior performance and environmental conditions
Data sourced from 2015-2019 Boston Marathon races.
Why Boston: The Boston marathon is one of the only marathons that require qualifying times for entry for a majority of runners which yields a high proportion of faster than average runners. The race is frequently characterized by extreme weather conditions, including warm and humid days.
Results: 136,161 race starters. Incidence of EHS was 3.7 cases per 10,000 starters.
Note: Twin Cities Marathon found 3 cases per 10,000 runners.
Mean age of runners was 43.3. Female 45%, male 55%.
Significant associations between sex and age, sex and start wave and age group and start wave.
Sex not associated with increased EHS incidence.
Age < 30 and assignment to the first 2 waves (faster runners) was significantly associated with increased EHS.
All cases of EHS occurred with average wet bulb globe temperatures (WBGT) were 17° – 20° C.
Linear correlation between EHS and incidence in addition to increases in WBGT from start to peak.
72.5% of cases were race finishers. Non finishers presented after mile 18.
Almost 30% developed post treatment hypothermia.
Almost 2/3rds were discharged directly, the remainder required hospital transport.
Authors estimate needing at least 4 ice water immersion tubs per 10,000 runners with potential of needing 8-10 if race day is humid.
Conclusions: Overall, EHS represented a small percentage of medical encounters but required significant resources.
Younger and faster runners are at high risk of EHS.
Greater increases in heat stress from start to peak worsens risk.
Definitions: WGBT - The Wet Bulb Globe Temperature (WBGT) is a measure of the heat stress in direct sunlight, which takes into account: ambient temperature, relative humidity, wind speed, sun angle and cloud cover (solar radiation). This differs from the heat index, which takes into consideration temperature and humidity and is calculated for shady areas.
Breslow RG, Collins JE, Troyanos C, Cohen MC, D'Hemecourt P, Dyer KS, Baggish A. Exertional Heat Stroke at the Boston Marathon: Demographics and the Environment. Med Sci Sports Exerc. 2021 Sep 1;53(9):1818-1825.
Category: Orthopedics
Keywords: pressure, exercise, lower extremity (PubMed Search)
Posted: 8/14/2021 by Brian Corwell, MD
(Updated: 12/12/2024)
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Chronic Exertional Compartment Syndrome (CECS)
Similar pathology to acute compartment syndrome except symptoms are related to activity (frequently running) and abate with rest.
95% involve lower extremity
Inappropriately elevated tissue pressure in one or more lower leg compartments associated with exercise
Anterior compartment most frequently involved
As tissue pressure increases, local perfusion is decreased. This leads to symptoms of pain, pressure, cramping and paresthesias.
Also commonly associated with team sports such as soccer, lacrosse and field hockey.
More likely in competitive athletes than recreational.
Patient will be symptom free at time of ED evaluation
Make diagnosis of CECS with history
Diagnosis with compartment pressure measurements done in office with treadmill exercise.
Non operatively, gait retraining programs have been shown to help symptoms. Appropriate if symptoms are mild.
Surgical treatment involves a minimally invasive fasciotomy
Post surgery success rates are between 63-100% with recurrence rates up to 20%
Category: Orthopedics
Keywords: ketamine, analgesia, morphine (PubMed Search)
Posted: 7/24/2021 by Brian Corwell, MD
(Updated: 12/12/2024)
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Low dose ketamine was compared to morphine for the treatment of patients with long bone fractures
126 patients with upper and lower extremity long bone fractures were divided into two treatment groups
Pain scores were compared pre and at 10 minutes post treatment
Pain severity significantly decreased in both groups to a similar degree
Increase adverse effects (emergence phenomenon) noted in ketamine group but all effects resolved spontaneously without intervention.
Conclusion: Analgesic effect of ketamine is similar to morphine in patients with long bone fractures.
Majidinejad S, Esmailian M, Emadi M. Comparison of Intravenous Ketamine with Morphine in Pain Relief of Long Bones Fractures: a Double Blind Randomized Clinical Trial. Emerg (Tehran). 2014;2(2):77-80.
Category: Orthopedics
Keywords: Lower back pain, NSAIDs (PubMed Search)
Posted: 7/10/2021 by Brian Corwell, MD
(Updated: 12/12/2024)
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NSAIDs for lower back pain (LBP)
NSAIDs are recommended for first line treatment of lower back pain.
Ibuprofen (600mg), ketorolac (10mg) and diclofenac (50mg) were compared.
3 arm, double-blinded study in an ED population with musculoskeletal LBP.
66 patients in each arm.
Outcomes via telephone interview 5 days later
Primary outcome was improvement in Roland-Morris Disability Questionnaire (RMDQ).
Lower scores indicate better LBP functional outcomes.
Secondary outcomes: Pain intensity and the presence of stomach irritation.
Baseline characteristics similar in 3 groups.
Results: No significant differences between 3 arms in primary outcome.
Ibuprofen 9.4, ketorolac 11.9, and diclofenac 10.9 (p = 0.34).
Ketorolac group reported less overall pain intensity at day 5.
Ketorolac group reported less stomach irritation that the other drugs ((p < 0.01).
While there was no differences in terms of functional outcomes, there may be a benefit of using ketorolac in terms of overall pain intensity and stomach irritation. This would benefit from further study in a larger population in order to draw definitive conclusions.
Irizarry E, Restivo A, Salama M, Davitt M, Feliciano C, Cortijo-Brown A, Friedman BW. A randomized controlled trial of ibuprofen versus ketorolac versus diclofenac for acute, nonradicular low back pain. Acad Emerg Med. 2021 Jun 16. doi: 10.1111/acem.14321. Epub ahead of print. PMID: 34133820.
Category: Orthopedics
Keywords: Exercise, wheezing, bronchospasm (PubMed Search)
Posted: 6/26/2021 by Brian Corwell, MD
(Updated: 12/12/2024)
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You are covering a sporting event or working an ED shift when a young adolescent athlete without significant PMH presents with SOB and wheezing associated with exercise.
You immediately think exercise-induced asthma, prescribe a short-acting bronchodilator and pat yourself on the back.
While you may be right, there is increasing recognition of an alternative diagnosis
Exercise-induced laryngeal obstruction (EILO)
During high intensity exercise, the larynx can partially close, thereby causing a reduction in normal airflow. This results in the reported symptoms of SOB and wheezing.
This diagnosis has previously been called exercise induced vocal cord dysfunction. As the narrowing most frequently occurs ABOVE the level of the vocal cord, EILO is a more correct term.
While exercise induced bronchoconstriction has a prevalence of 5-20%, EILO is less common with a prevalence of 5-6%.
Patients are typically adolescents, with exercise associated wheezing and SOB, frequently during competitive or very strenuous events. Wheezing is inspiratory and high-pitched. Symptoms are unlikely to be present at time of medical contact unless you are at the event as resolution occurs within 5 minutes though associated cough or throat discomfort can persist after exercise cessation. EIB symptoms typically last up to 30 minutes following exercise.
Inhaler therapy is unlikely to help though some athletes report subjective partial relief. This may be explained as approximately 10% of individuals have both EIB and EILO.
In athletes with respiratory symptoms referred to asthma clinic, EILO was found in 35%.
Consider EILO in athletes with unexplained respiratory symptoms especially in those with ongoing symptoms despite appropriate therapy for EIB.
Category: Orthopedics
Keywords: hand elevation test, (PubMed Search)
Posted: 6/12/2021 by Brian Corwell, MD
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Hand elevation test
https://www.youtube.com/watch?v=IO2qC5qHVFE
1) Ahn DS. Hand elevation: a new test for carpal tunnel syndrome. Ann Plast Surg. 2001
2) Ma H, Kim I. The diagnostic assessment of hand elevation test in carpal tunnel syndrome. J Korean Neurosurg Soc. 2012 Nov;52(5):472-5.
Category: Orthopedics
Keywords: Epidural abscess, back pain, vertebral osteomyelitis (PubMed Search)
Posted: 5/8/2021 by Brian Corwell, MD
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Both erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are highly sensitive (84-100%) for spinal infections and are observed in >80% with vertebral osteomyelitis and epidural abscesses.
ESR
Most sensitive and specific serum marker, usually elevated in both spinal epidural abscess (SEA) and vertebral osteomyelitis.
ESR was elevated in 94-100% of patients with SEA vs. only 33% of non-SEA patients
Mean ESR in patients with SEA was significantly elevated (51-77mm/hour)
CRP
Not highly specific
Less useful for acute diagnosis since CRP levels rise faster and return to baseline faster than ESR (elevated CRP seen in 87% of patients with SEA as well as in 50% of patients with spine pain not due to a SEA)
Better used as a marker of response to treatment.
1) Colip CG, Lotfi M, Buch K, Holalkere N, Setty BN. Emergent spinal MRI in IVDU patients presenting with back pain: do we need an MRI in every case? Emerg Radiol 2018;25:247-56.
2) Davis DP, Salazar A, Chan TC, Vilke GM. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain. J Neurosurg Spine 2011;14:765-70.
Category: Orthopedics
Keywords: SEA, ESR, spinal infection (PubMed Search)
Posted: 4/24/2021 by Brian Corwell, MD
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Erythrocyte sedimentation rate (ESR) for spinal infection
Sensitive for spinal infection but not specific
Elevated ESR is observed in greater than 80% of patients with vertebral osteomyelitis and epidural abscess
ESR is the most sensitive and specific serum marker for spinal infection
Usually elevated in acute presentations of SEA and vertebral osteomyelitis
ESR was elevated in 94-100% of patients with SEA vs. only 33% of non-SEA patients
Mean ESR in patients with SEA was significantly elevated (51-77mm/hour)
Infection is unlikely in patients with an ESR less than 20 mm/h.
Incorporating ESR into an ED decision guideline may improve diagnostic delays and help distinguish patients in whom MRI may be performed on a non-emergent basis
1) Davis DP, et al. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain. J Neurosurg Spine 2011;14:765-767.
2) Reihsaus E, et al. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev 2000;23:175,204
Category: Orthopedics
Keywords: Concussion, mTBI, exercise prescription (PubMed Search)
Posted: 4/10/2021 by Brian Corwell, MD
(Updated: 12/12/2024)
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A total of 367 patients were enrolled. Median age was 32 years Male 43%/Female 57%.
Result: There was no difference in the proportion of patients with postconcussion symptoms at 30 days. There were no differences in median change of concussion testing scores, median number of return PCP visits, median number of missed school or work days, or unplanned return ED visits within 30 days. Participants in the control group reported fewer minutes of light exercise at 7 days (30 vs 35).
Conclusion
Prescribing light exercise for acute mTBI, demonstrated no differences in recovery or health care utilization outcomes.
Extrapolating from studies in the athletic population, there may be a patient benefit for light exercise prescription.
Make sure that the patient is only exercising to their symptomatic threshold as we recommend with concussed athletes. Previous studies have shown that athletes with the highest post injury activity levels had poorer visual memory and reaction time scores than those with moderate activity levels.
Varner et al. A randomized trial comparing prescribed light exercise to standard management for emergency department patients with acute mild traumatic brain injury. Acad Emerg Med. 2021.
Category: Orthopedics
Keywords: patellofemoral, knee, pain (PubMed Search)
Posted: 3/13/2021 by Michael Bond, MD
(Updated: 12/12/2024)
Click here to contact Michael Bond, MD
Bottom Line: In a recent meta-analysis the risk factors for patellofemoral syndrome are weak hip abduction strength, quadricep weakness in military recruits, and increased hip strength in adolescence.
PatelloFemoral Syndrome: Patellofemoral pain is not clearly understood and is believed to be multi-factorial. Numerous factors have been proposed including muscle weakness, damage to cartilage, patella maltracking, as well as others. Patient often complain of anterior knee that is aggravated by walking up and down stairs or squatting. Patellofemoral pain is extremely common. In the general population the annual prevalence for patellofemoral pain is approximately 22.7%, and in adolescents it is 28.9%.
Though commonly taught, the following have no evidence to support that they are a risk factor for patellofemoral syndrome: Age, Height, Weight, BMI, Body Fat or Q Angle of patella
Category: Orthopedics
Keywords: Distal radius fracture, wrist, splint (PubMed Search)
Posted: 2/27/2021 by Brian Corwell, MD
(Updated: 12/12/2024)
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Home management versus PCP follow-up of patients with distal radius buckle (torus) fractures
A recent study investigated outcomes of patients with distal radius buckle fractures who were randomized to
Versus
Noninferior study
Torus/buckle fractures of the distal radius are the most common fractures in childhood occurring on average in 1 in 25 children
This is a stable fracture typically treated with removable wrist splint and very rarely require orthopedic intervention
Outcome: functional recovery at 3 weeks
Randomized controlled trial at a tertiary care children’s hospital
All radiographs reviewed by pediatric radiologist with MSK specialization
149 patients. Mean age 9.5 years. 54.4% male
Telephone follow-up at 3 and 6 weeks following ED discharge by blinded interviewer
Primary outcome was comparison of Activities Scale for Kids-performance scores between groups at 3 weeks
Outcomes: Home management performance score was 95.4% and PCP follow-up group was 95.9%. Mean cost savings were $100.10.
Conclusion: Home management is at least as good as PCP follow-up with respect to functional recovery in ED patients with distal radius buckle fractures.
Colaco et al. Home management versus primary care physician follow-up of patients with distal radius buckle fractures: A randomized controlled trial. Ann Emerg Med. 2021
Category: Orthopedics
Keywords: diabetes, exercise, weight loss (PubMed Search)
Posted: 2/13/2021 by Brian Corwell, MD
(Updated: 12/12/2024)
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What time of day is best for exercise to achieve weight loss goals?
Working out in the morning has traditionally held the edge, especially if done on an empty stomach.
Upon walking, elevated levels of cortisol and GH will aid in fat metabolism.
Switching to a morning workout may also decrease appetite throughout the day.
Morning exercise may also induce significant circadian phase?shifting effects. Patients report feeling more alert in the morning and get more tired at night. This may “force” people to get increased rest as poor sleep quality and duration has been associated with weight gain.
Moderate intensity aerobic exercise has been shown to cause immediate mood improvement and mental productivity. These effects can last up to 12 hours and may be a simple aid to combat job stress.
However, a recent small study looked at this question with a group of men at high risk for Type 2 diabetes.
Those that exercised in the morning had better blood sugar control and lost more abdominal fat than those who exercised in the morning.
Study: 32 adult males (58 ± 7 years) at risk for or diagnosed with type 2 diabetes performed 12 weeks of supervised exercise training either:
In the morning (8.00–10.00 a.m., N = 12) OR
In the afternoon (3.00–6.00 p.m., N = 20)
Test: Graded cycling test with ECG monitoring until exhaustion
Results: Compared to those who trained in the morning, participants who trained in the afternoon experienced superior beneficial effects of exercise training on peripheral insulin sensitivity, insulin?mediated suppression of adipose tissue lipolysis, fasting plasma glucose levels, exercise performance and fat mass.
Conclusion: Metabolically compromised patients may benefit from shifting their exercise routine to the afternoon from the morning. Ultimately, any exercise is great in this population, but this study may be worth sharing to your patients.
Mancilla R, Brouwers B, Schrauwen-Hinderling VB, Hesselink MKC, Hoeks J, Schrauwen P. Exercise training elicits superior metabolic effects when performed in the afternoon compared to morning in metabolically compromised humans. Physiol Rep. 2021 Jan;8(24):e14669.
Category: Orthopedics
Keywords: tendon, antibiotics (PubMed Search)
Posted: 1/9/2021 by Brian Corwell, MD
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A recent retrospective observational study looked at the association of oral antibiotics (primarily fluroquinolones) and tendon rupture.
Outcome data is very interesting for our practice, deviates from traditional teaching.
Population: 1 million Medicare fee for service beneficiaries from 2007-2016 (>65 years old)
Antibiotics queried: Seven total oral antibiotics of mixed class:
Outcome measures: all combined tendon ruptures and 3 by anatomic site (Achilles, rotator cuff {RC} and other)
Results: Of the 3 quinolones, only LEVOfloxacin showed a significant increase in risk of tendon rupture (16% for RC) and (120% for Achilles) in a 1 month window. The others did not show an increased risk
Among the other antibiotics, cephalexin showed an increase risk across all anatomic sites.
The authors note that the risk with levofloxacin never exceeded the risk of cephalexin in any comparison!
Baik S, Lau J, Huser V, McDonald CJ. Association between tendon ruptures and use of fluoroquinolone, and other oral antibiotics: a 10-year retrospective study of 1 million US senior Medicare beneficiaries.
BMJ Open. 2020;10(12):e034844. Published 2020 Dec 21.
Category: Orthopedics
Keywords: Hip pain, snapping hip, tendon (PubMed Search)
Posted: 12/27/2020 by Brian Corwell, MD
(Updated: 12/12/2024)
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Chief complaint: “My hip snaps when I exercise”
Both athletes and non-athletes may report a “snapping” sound with certain movements
This may affect up to 10% of the population
May be associated with activities than involve repetitive hip flexion
Symptoms may be due to an internal or an external cause
External causes are usually due to a tendon passing over a bony prominence
This can be felt as either an audible sensation and/or even a palpable snap
This may or may not involve pain or discomfort
This is most commonly due to a benign cause
During movements in flexion, extension or combined with internal rotation the iliotibial band may move over the greater trochanter.
Alternatively, the hamstring tendon may pass over the ischial tuberosity
There are several other causes with similar mechanisms
Symptoms are usually minimal and not serious
This can be reproduced on bedside clinical exam
Ask the patient to identify the area of snapping with one finger which will help with anatomic localization
First line therapy is physical therapy which focuses on:
Improving muscle length if muscle is too tight OR
Improving neuromuscular activation if problem is due to excessive muscle activation
Category: Orthopedics
Keywords: Balance, mBESS, concussion (PubMed Search)
Posted: 12/12/2020 by Brian Corwell, MD
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The Romberg test is part of the standard neurologic examination. The patient is asked to stand with feet together, hand on hips/sides and the eyes are closed. Vestibular and proprioceptive input is being tested.
This test is not very sensitive overall, but especially in concussed athletes.
Many concussed athletes are able to stand relatively stable despite their neurologic injury.
In order to better identify postural instability in concussion, we perform 3 separate balance tests (modified balance error scoring system, mBESS).
A) Romberg
B) Single leg stance
C) Tandem Stance
Have patient stand quietly with hands on hips
Have patient close eyes and start 20 second trial
If error occurs tell patient to return to start as quickly as possible
Examples of errors: opening eyes, lifting hands, falling out of position
Category: Orthopedics
Keywords: Shoulder, biceps, tendon (PubMed Search)
Posted: 11/28/2020 by Brian Corwell, MD
(Updated: 12/12/2024)
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A 25 year old athlete presents to the ED with right anterior shoulder pain.
Pain radiates into proximal biceps.
It is worse with heavy lifting and especially “pulling” exercises at the gym.
How do we evaluate for biceps tendonitis?
Pathology is often the long head of the biceps
https://physioworks.com.au/wp-content/uploads/2019/12/biceps-tendonitis.jpg
Start by palpating this area and attempt to reproduce the discomfort
Speed’s test
Yergason’s test
Category: Orthopedics
Keywords: Elbow, dislocation, instability (PubMed Search)
Posted: 10/25/2020 by Brian Corwell, MD
(Updated: 12/12/2024)
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Ulnar Collateral ligament injuries of the elbow
Overhead throwing athletes are at risk of insufficiency and rupture of the ulnar collateral ligament (UCL) of the elbow
This can lead to valgus instability similar to what can occur in the knee
Overhead throwing places a significant valgus stress on the elbow
Though classically seen in baseball pitchers, may also be seen in javelin throwers and other high velocity throwing sports
In the acute setting may be seen after an elbow dislocation
History includes a “pop” and medial elbow pain following throwing activities
In cases of overuse injury, athletes will report a progressive loss of velocity, accuracy, and/or endurance with throwing.
The ulnar collateral ligament is the primary restraint to valgus stress from 30 to 120 degrees of flexion
One classic test for UCL instability is the milking maneuver
Patient may be sitting or standing
Patient’s forearm is supinated and elbow flexed at 90 degrees
A valgus force is applied by pulling the patient’s thumb while the examiner’s other hand stabilizes the elbow and palpates the medial joint line.
Instability, pain or apprehension at the UCL is considered a positive test
https://www.youtube.com/watch?v=gbn24X_qqn0
Category: Orthopedics
Keywords: Carpal Tunnel Syndrome, neuropathy (PubMed Search)
Posted: 10/10/2020 by Brian Corwell, MD
(Updated: 12/12/2024)
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Carpal Tunnel Syndrome (CTS)
The hallmark of classic CTS: pain or paresthesia (numbness and tingling) in a distribution that includes the median nerve territory, with involvement of the first three digits and the radial half of the fourth digit.
The symptoms of CTS are typically worse at night and often awaken patients from sleep.
Fixed sensory loss is usually a late finding
Involves the median-innervated fingers BUT spares the thenar eminence.
This pattern occurs because the palmar sensory cutaneous nerve arises proximal to the wrist and passes over, rather than through, the carpal tunnel.
Consider a more proximal lesion in cases involving sensory loss in the thenar eminence
Example: pronator syndrome
Category: Orthopedics
Keywords: Elder abuse, bruising, trauma (PubMed Search)
Posted: 9/26/2020 by Brian Corwell, MD
(Updated: 12/12/2024)
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Physical injury patterns associated with physical elder abuse
Elder abuse is both common and underrecognized
Between 5 and 10% of US older adults are victims of elder abuse annually
For many older adults, contact with a health care provider may represent their only contact outside the home
Differentiating physical elder abuse from unintentional trauma can be very difficult
A recent study compared these two groups with a case-control design
Study cases: 100 successfully prosecuted physical elder abuse cases from a single urban ED
Physical abuse victims were more likely to have:
Bruising (78% vs. 54%)
Injuries to maxillofacial, dental or neck region (67% vs. 28%)
Particularly the LEFT side
Neck injuries 6x more common is assault
Ear injuries occurred in assault but not in falls
Absence of fracture (8% vs. 22%)
Less likely to have lower extremity injuries (9% vs. 41%)
22% of victims had no visible injuries
Most common mechanism assault with hands or fists and pushing or shoving causing a fall
Take home: Consider elder abuse especially in cases of the above red flags
Rosen T, et al. Identifying Injury Patterns Associated With Physical Elder Abuse: Analysis of Legally Adjudicated Cases. Ann Emerg Med. 2020 Sep;76(3):266-276.