Exertional Heat Stroke (EHS)

With football preseason starting across the country, it is important to review this topic

EHS is a medical emergency resulting from progressive failure of normal thermoregulation

EHS has a high mortality

               -2^nd most common cause of death in football players

History and Exam

Hyperthermia/Core temperature greater than 40°C (104°F)

Initial profuse sweating with eventual cessation of sweating with hot, dry skin

CNS dysfunction – disorientation, confusion, dizziness, inappropriate behavior, difficulties maintaining balance, seizures, coma

Other: Tachycardia/hyperventilation, fatigue, vomiting, headache

Multi-organ involvement: CNS, cardiac damage, renal failure, hepatic necrosis, muscle (rhabdomyolysis), GI (ischemic colitis), heme (DIC), ARDS

The single most important thing you can do on the field is recognize this entity. Early recognition leads to earlier initiation of treatment which is life saving.

Rapid cooling is key. This is often stated but what this means is whole body immersion in ice water. This should be available and ready for all summer practices.

The temperature needs to be lowered to below 39°C (102°F)

Also consider a cooling blanket, fanning, ice to body

DO NOT put them on ambo without initiating cooling!!!

Sustaining heat injury predisposes to subsequent heat related injury

Delayed Onset Muscle Soreness (DOMS), aka “muscle fever”

Muscle pain and weakness following unfamiliar exercise

Occurs after high force, novel (unaccustomed) eccentric muscle contractions

               Occasionally isometric in an extended position

Eccentric exercise – controlled elongation

Slowly lowering yourself to start position doing pullups for example

Time of onset

Begins 6 to 12 Hours after exercise, Peaks 2-3days post and resolves in 5-7 days

               Speed of onset and severity are often related

How do you know if you have it?

Much like the flu, you know it when you have it. The simple act of getting out of a car, sitting down or walking down stairs is excruciatingly painful.

Cause:

Exact cause is unknown. Thought to be due to sarcolemma damage leading to intra cellular calcium release and activation of proteolytic enzymes. Creatine kinase leaks from muscle cells into plasma attracting inflammatory cells.

Treatment:

Best treatment is prevention: Repeated bout effect – a bout of eccentric or isometric exercise can prevent DOMS from the same exercise for 4-12 weeks.

               Stretching before exercise has not been shown to be effective prevention

Other modalities: rest, ice, heat, massage, electrical stimulation

Take home:

Eccentric exercises or novel activities should be introduced progressively over a period of 1 or 2 weeks at the beginning of the sporting season or the start of a new, novel exercise routine. For example, not starting the Insanity day one workout without “pretraining.” This will reduce the level of physical impairment and/or training disruption and lead to gains with much less pain.

Stingers and Burners

Also known as transient brachial plexus neuropraxia, “dead arm syndrome,” or brachial plexopathy. Symptoms such as pain, burning, and/or paresthesias in a single upper limb, lasting seconds to minutes.

Usually involves more than one dermatome

May be associated with weakness.

               -Common in collision sports that involve tackling, such as football.

               -Most common C-spine injury in American Football.  

               -More than 50% of college football players sustain a stinger each year

-Having 1 stinger increases the risk of having another 3 fold

Mechansims: C5, C6 (deltoid,biceps) most commonly involved

-Traction injury due to forcible lateral neck flexion away with downward displacement of arm

-Nerve root compression during combined neck extension and lateral neck flexion

-Direct trauma to the brachial plexus in the supraclavicular fossa

Physical Exam:

-Examine muscle strength in the deltoid, biceps, and infraspinatus muscles

-Check sensation and reflexes in upper extremities

-Check C-spine range of motion and perform Spurling’s Test

Imaging:

Consider MRI for symptoms lasting more than 24 hours, bilateral symptoms or for recurrent stingers

Return to play guidelines vary:

-No neurologic symptoms

-Can return to play in same game if symptoms resolve within 15 minutes and no prior stingers that season.

-If 2^nd stinger in that season, do NOT return to play in the same game

-if 3^rd stinger in a season, consider imaging before return to play and consider sitting out the remainder of the season.

ED visits for acute gout increased almost 27% between 2006 & 2014, a 26.8% increase

Presentation: Acute severe pain, swelling, redness, warmth.

Pain peaks between 12 to 24 hours and onset more likely at night

Quiet, calm period between flares vs other arthritic disorders

Signs of inflammation can extend beyond the joint

Normal to low serum urate values have been noted in 12 to 43% of patients with gout flares 

Accurate time for assessment of serum urate is greater than 2 weeks after flare subsides

Most hyperuricemic individuals never experience a clinical event resulting from urate crystal deposition.

Gout flares may occasionally coexist with another type of joint disease (septic joint, psedugout),

A clinical decision rule has shown to be more accurate than clinical diagnosis (17 versus 36%)

*Male sex (2 points)

*Previous patient-reported arthritis flare (2 points)

*Onset within one day (0.5 points)

*Joint redness (1 point)

*First metatarsal phalangeal joint involvement (2.5 points)

*Hypertension or at least one cardiovascular disease (1.5 points)

*Serum urate level greater than 5.88 mg/dL (3.5 points)

 Scoring for low (≤4 points), intermediate (>4 to <8 points), and high (≥8 points) probability of gout identified groups with a prevalence of gout of 2.2, 31.2, and 82.5 percent, respectively.

Consider supplementing your clinical decision with this in the future

Show References

Bottom Line:

Less than 1/2 of patients presenting to EDs and being diagnosed with concussion receive mild traumatic brain injury educational materials, and less than 1/2 of patients have seen a clinician for follow up by 3 months after injury.

In order to improve long term outcomes in patients with concusions please remember to provide the patient with approriate discharge instrucitons and strict instructions to follow up on their injury.

Full details of the article in JAMA can be found at https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2681571

Syndesmotic sprain aka a “high ankle sprain”

Ankle injuries make up almost 30% of the injuries in professional football

High ankle injuries make up between 16 and 25% of these injuries in the NFL (lateral most common)

               10% in general population

In comparison to lateral ankle sprains, high ankle sprains result in significantly more missed games, missed practices and required a longer duration of treatment

Anatomy: The syndesmosis comprises several ligaments and the interosseous membrane

Mechanism: External foot rotation with simultaneous rotation of the tibia and fibula.

               Can lead to a Maisonneuve fracture

Injuries 4x more likely in game setting than practice

A positive proximal squeeze test significantly predicts missed games and practices compared to those without.

https://www.youtube.com/watch?v=ThiW_9m7cFM

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Exertional rhabdomyolysis (ER)

The warm weather is here and with it comes an increased risk of ER

Risks include the intensity, duration and types of exercises performed

One of the biggest risks is the exercise experience of the participants, both in those with little to no experience and in those experienced athletes less trained than their counterparts.

Multiple case reports find that intense novel exercises early in the preseason before getting acclimatized and “in shape” carry great risk to the participant. These can be summarized as “too much, too soon, too fast.”

Coaches need to be educated about this and be prepared to detect and effectively handle ER through an emergency action plan.

               -Conditioning workouts need to be phased in rather than start at maximum intensity on day one.

Eccentric exercises appear worse than concentric exercises.

Has been seen in almost all sports, ranging from swimming to golf.

               It’s not just preseason football!

High humidity and high temperature environments increase the likelihood of ER

Males are more vulnerable to ER than females

Increased risk with sickle cell trait and glycogen storage diseases

Multiple drugs may increase individual risk including alcohol, cocaine, amphetamines, MDMA and caffeine.

Implicated medicines include, salicylates, neuroleptics, quinine, corticosteroids, statins, theophylline, cyclic antidepressants and SSRIs

Show References

Does mild traumatic brain injury increase risk of dementia?

Background: Most studies of moderate to severe TBI have found an association with increased risk of dementia and earlier onset of Alzheimer’s. There is growing concern that repeated TBIs, even if more mild, can lead to neurodegenerative conditions such as chronic traumatic encephalopathy (CTE). However, the link between mild TBI and dementia risk has not fully been elucidated, especially in the case of mild TBI without loss of consciousness (LOC).

Recent Data: A recent JAMA study evaluated the association between TBI severity, LOC, and dementia diagnosis in 350,000 veterans between 2001-2013. After adjusting for demographics as well as medical and psych comorbidities, veterans with even mild TBI without LOC had more than a 2-fold increase in risk of dementia diagnosis than those with no TBI. The risk increased only slightly if there was LOC (from a hazard ratio of 2.4 to 2.5). Risk was >3-fold for those with moderate-severe TBI.

Take home: TBI of any severity, even without LOC, appears to be associated with long term neurodegenerative consequences. Avoidance of TBI is of the utmost importance, and if TBI occurs, close neurocognitive follow up should occur.  

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Exercise talking points for the pregnant patient

(from ACSM 2017 Consesnsus statement)

Exercise throughout pregnancy is generally safe but should be monitored

No evidence of higher rates of preterm or prolonged labor, or deliveries that require induction or episiotomy

No evidence of negative effect on APGAR scores

Other benefits:

Avoidance of excessive weight gain, improved balance, and decreased back pain

Improved well-being, energy levels, and sleep patterns

Improved labor symptoms and facilitation of post-partum recovery

Lower risk of C-section

Reduced risk of having a large for gestational age (LGA) or small for gestational age (SGA) infant

Risks include environmental exposure, dehydration, hypoxia, and uterine trauma:

High impact or high-strain physical activity during the fetal implantation phase may lead to slightly higher risk of miscarriage

Sports with high risk of trauma last in pregnancy could result in placental abruption

Scuba diving is contraindicated because the fetus is not protected from decompression problems

Limit use of sauna or hot tub to fewer than ten minutes or omit altogether

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Female Athlete Triad

1. Low energy availability
   1. With or without eating disorders
2. Menstrual dysfunction
3. Low bone mineral density (BMD)

Energy availability considers the amount of remaining energy for metabolic processes based on calories takin in with eating and calories burned through exercise or both.

Menstrual dysfunction occurs as a result of low energy availability causing decreased GnRH inhibition and ovarian suppression and decreased estrogen.

Low bone mineral density occurs due to amenorrhea and decreased energy availability. Estrogen limits bone resorption (stimulates calcitonin and renal calcium retention).

This is very important for young girls as by age 12 they have 83% of their total BMD & 95% two years after menarche.

If you see an athlete in the ED with one component of the triad, inquire about the other two. A 15yo athlete with a stress fracture may not realize that her disordered eating, excessive exercise or amenorrhea may by contributing factors and may benefit from follow up with PCP, dietitian, Gyn, etc.

Boutonniere Deformity
aka buttonhole deformity

Misdiagnosed as a “jammed” or “sprained” finger

• Deformity occurs at the PIP joint
• Trauma to the PIP joint can cause the joint capsule to tear, the head of the phalanx can buttonhole thru the defect and the lateral bands of the extensor tendons fall laterally & contract
• The lateral bands then function as PIP flexors and not extensors
• DIP hyperextension due to excessive pull of the displaced lateral bands
• As a result, the pateint WILL be able to flex the DIP joint, but WILL NOT be able to extend   the PIP joint                                                                    
• OCCURS 1 - 3 weeks post injury
• May not present with classic textbook deformity
• The Elson test is the best way to detect the injury pattern before the deformity is evident
• https://www.youtube.com/watch?v=G9HY0qXWUvE

Pectoralis Major Rupture

Most commonly seen in male weightlifters

Usually occurs as a tendon avulsion

Incidence is increasing

Hx: Sudden, sharp, tearing sensation with pain and weakness with arm movement

PE: Palpable defect and deformity of anterior axillary fold. Bruising and swelling.

               Deformity may not be obvious with arm by side and relaxed

Testing: Weakness with ADDuction and internal rotation

https://lh3.googleusercontent.com/wQcuu_sG76t_DLWocO_c2344IT69g_vWXY0FKtqhR4L37qrrsIuW607LZkVFT8QTLAdaTeU=s170

Treatment:  Operative treatment has better outcomes but depends on patient subgroups

Nonoperative treatment generally indicated for partial ruptures and tears in the body of the pec and muscle tendon junction

               Sling, ice and pain control.

Operative treatment generally for high demand patients (athletes) and bony avulsion injuries

The search for an objective reliable test for mild traumatic brain injury found an early promising result last week.

               May be arriving in your hospital in the near future.

               A handheld sideline version is sure to follow

The FDA approved the first blood test for concussion/mild TBI

               Called the Banyan BTI (Brain Trauma Indicator)

This test measures 2 neural protein biomarkers released into the blood following mild TBI

The FDA approved this test within 6 months after reviewing data on just under 2,000 blood samples.

               They concluded the Banyan BTI can predict the absence of cranial CT lesions with an accuracy greater than 99% and may reduce imaging in up to a 1/3^rd

Be optimistic but consider the small sample size and remember that this test looks for biomarkers and may miss subtle cases where proteins didn’t leak. This test is NOT ready to be used for return to play decisions. It takes 3 to 4 hours to result and costs about $150. Other biomarkers are being investigated and may prove to be better

https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm596531.htm

Femoral neck stress fractures

Adults>kids

Represents 5% of all stress fractures

Usually due to repetitive abductor muscle contraction

As with all stress fractures can occur in 2 types

1)      Insufficiency type (normal physiologic stress on abnormal bone)

2)      Fatigue type (abnormal/excessive physiologic stress on normal bone)

2 locations on interest:

1)      Compression side (inferior femoral neck)

2)      Tension side (superior femoral neck)

History: Insidious onset of groin or lateral hip pain associated with weight bearing

Exam: Antalgic gait, pain with hip log roll and with FABER (hip flexion, Abduction and external rotation test)

Treatment:

Compression side: reduced weight bearing and activity modification

Tension side:  Non weight bearing (due to high risk of progression to displacement with limited weight bearing) AND surgical consultation for elective pinning to prevent displacement. If displaced, will require ORIF

Show References

Dental Avulsion in the field/sporting event

-  Only replace avulsed secondary teeth

-  Handle the tooth by the crown only

-  Rinse tooth with cold running water gently (the root should not be wiped)

-  Immediate attempt to reimplant permanent tooth into socket by 1st capable person:

*  Time is tooth: Each minute tooth is out of socket reduces tooth viability by 1%

*  Best chance of success if reimplant done within 5–15 min*?  Poor tooth viability if avulsed for >1 hr

-  If unsuccessful, place tooth in a transport solution (from most to least desirable):

-  Hanks balanced salt solution (HBSS)

*  Balanced pH culture media available commercially in the Save-A-Tooth kit

*  Effective hours after avulsion

-  Cold milk:

*  Best alternative storage medium

*  Place tooth in a container of milk that is then packed in ice (prevents dilution)

-  Saliva:

*  Store in a container of parent or child's saliva

-  Never use tap water or dry transport

Concussion – Where are we now?

The Sport Concussion Assessment Tool 5^th edition (SCAT 5) was released in 2017

It is a standardized tool to assist health care professionals in the evaluation of sport associated concussions

It should be used for those 13 years and older (there is a child version for younger athletes)

Print and bring to the sideline for your next coverage event!

http://bjsm.bmj.com/content/bjsports/early/2017/04/26/bjsports-2017-097506SCAT5.full.pdf

Some points to consider:

It should take at least 10 minutes to complete. Any less and you may not be performing the test correctly

The SCAT5 is the standard tool used in concussion assessment in the NCAA and NFL and other professional sports

Some symptoms of concussion appear over time. For example, an athlete may have zero or minimal symptoms immediately after yet be considerably symptomatic in 10 to 15 minutes.

               -Follow up screening evaluations are essential even in those with a negative initial sideline screening test

The SCAT5 should be used immediately after injury

               -Utility decreases post injury after days 3-5

               -The included symptom checklist has utility in tracking recovery

               -Attempt to perform in an environment free of distractions (crowd noise, bad weather)

The clinical utility of the SCAT5 can be enhanced by adding assessment of other factors such as reaction time, balance assessment, video-observable signs (if available) and oculomotor screening.

CC: 12yo boy presents with pain to base of 5^th metatarsal

Osteochondrosis overuse syndromes associated with development of secondary ossification or apophyseal centers

Iselin disease – Osteochondrosis of 5^th MT base

Lateral 5th foot pain with weight bearing and activity in early adolescence

Child may limp or walk on inner part of foot

               Adolescents:  Girls >10, Boys >12

               Commonly seen in soccer, basketball, gymnastics and dance

Exam: Tenderness to palpation at proximal 5^th MT at peroneal brevis insertion

Area may show edema and redness

Pain with foot inversion and resisted eversion and dorsiflexion

XR: May be normal or show enlargement or fragmentation of epiphysis

Obliquely oriented small bony fleck at 5^th MT base. Parallel to long axis of 5^th MT. Best seen on oblique view. Unlike fractures which tend to be horizontally oriented.

Treatment: Immobilize for comfort if severe (walking boot) or simple activity modification if mild. Ice and calf muscle stretching.

http://https://images.radiopaedia.org/images/2343487/d3478d2024c845ba0f2fffffd7d51c_big_gallery.jpg

Tibial shaft stress fractures

An overuse injury where the tibia is subjected to repetitive stress resulting in progressive microfractures

Commonly seen in runners and military recruits

Location of injury is very important for prognosis and treatment

1)      Medial tibia (compression side) – Most common stress fracture site in athletes (runners)

2)      Anterior tibia (tension side) – Seen in repetitive jumping  athletes

History: Change in routine (volume or surface), Insidious onset of pain, worse with activity better with rest

Exam: Focal tenderness to palpation (versus larger diffuse area with shin splints)

Radiology: Plain film often normal in first 2 to 3 weeks

Lateral X-ray may show the “dreaded black line” on the anterior tibia

MRI has replaced bone scan as most sensitive for early diagnosis. Fracture line surrounded by edema.

Treatment:

Medial fractures: relative rest (avoid painful activities), avoid NSAIDs, PT, gradual return to activity as dictated by symptoms

VERSUS

Anterior stress fractures:  Very high risk injury pattern (delayed union and non union). Non weight bearing splint/cast. Intramedullary nail often used for failure of conservative treatment or earlier return to sport in competitive athletes.

Dreaded black line picture:

https://www.researchgate.net/profile/Brian_Werner2/publication/265054294/figure/fig2/AS:295959096512514@1447573555901/Figure-2-A-Lateral-plain-radiograph-showing-the-%27%27dreaded-black-line%27%27-highlighted.png

A recent article from JAMA (link below) showed that Ibuprofen and opioids are similarly effective in the short term relief of acute extremity pain when used in combination with acetaminophen.  The study looked at adults with fractures and sprains and randomized them to one of four groups.

• 400mg Ibuprofen and 1000mg acetaminophen
• 5mg Oxycodone and 325mg acetaminophen 
• 5mg Hydrocodone and 300mg acetaminophen
• 30mg Codeine and 300mg acetaminophen

Pain relief was similar in all groups.

With the growing increase in opioid abuse/addiction it is good to know that in our patients that are not allergic to acetaminophen and ibuprofen (or all medications except for that one that begins with a “D”) we can provide good pain relief without using opioids.

https://jamanetwork.com/journals/jama/article-abstract/2661581

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Parsonage Turner syndrome aka Neuralgic amyotrophy

30 cases per 100,000

Under recognized and often missed

Unknown cause, perhaps post viral. Also reported post stress (surgery, pregnancy)

Can be B/L in 10 to 30%

CC: sudden onset of severe pain in the shoulder.

Can last for hours to weeks.

Radiates to upper arm.

As pain begins to subside, muscle weakness and sensory loss follows.

Can preferentially involve the suprascapular and axillary nerve.

Outpatient workup may include MRI and EMG

Treatment: Supportive. Consider a trial of oral steroids. Provide good pain control.

Majority of patients improve within 3 months. Though up to a third have persistent pain/functional deficit.