hot topics in sports disclosure medicine luke hot topics 2015.pdf• concussion grading is...

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Hot Topics in Sports Medicine

Anthony Luke MD, MPH

UCSF Primary Care Medicine: Principles and Practice 2015

Disclosure

• Founder, RunSafe™• Founder, SportZPeak Inc.

• Research grant, Sanofi• Research grant, Intel

Outline

• Managing Overuse injuries

• What’s new with Patellofemoral pain

• Concussions

Overuse Injuries

• Occur due to repetitive submaximal loading of the musculoskeletal system when rest is not adequate to allow for structural adaptation to take place.

DiFiori et al. Overuse Injuries and Burnout in Youth Sports: A Position Statement from the American Medical Society for Sports Medicine, accepted for publication, 2014.

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Key Features

• Repetitive loading (rather than traumatic)

• Overwhelm the ability of the tissue to remodel, resulting in a weakened, damaged structure

• Imbalance between training loads and recovery is a key factor

• Mechanism Preventable?

Windlass Mechanism

Midstance Toe - off

Achilles Tendinopathy

Mechanism

• Repetitive eccentric load on tendon

• Pushing off, running, sprinting, jumping

Presentation• Tender over

achilles +/- swelling• Pain with resisted

toe off• Pain with passive

ankle dorsiflexion

Risk FactorsKhan KM, et al. Phys Sportsmed 2000.

• Tight Achilles and plantar fascia• Hyperpronation• Cavus foot• Advancing age - decreased blood flow• Overweight • Poor footwear• Weak hip abductors and medial

quadriceps

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Plantar Fascitis• Tender on insertion on medial aspect of

heel• Associated with:

– Age– Pes planus and pes cavus– Obesity (OR =5.6 (95% C.I., 1.9-16.6)– Poor shoes, working on feet (OR = 3.6

(95% C.I., 1.3-10.1)– ≤0 degrees of dorsiflexion had OR = 23.3

(95% C.I. , 4.3 to 124.4) Riddle et al. JBJS-A, 2003

– Limb leg discrepancy (longer leg associated with plantar fasciitis)

Mahmood et al, J Am Podiatr Med Assoc, 2010

Tendinosis

• Hyaline degeneration

• Mucoid degeneration

• Fibrillation of collagen

• Absence of inflammatory cells

Mechanics

• Usually tendons surrounding joints with high degree of motion

• Usually tendons that cross two joints

• Eccentric overload• Mechanical

impingement• Temperature

breakdown• Angiogenesis?

Conservative Treatment

REDUCE STRESS• Modified activities, ice

• Calf / Achilles stretching

• Hold each stretch for 30 seconds

Soleus stretch

Gastrocnemius stretch

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Treatment

• Heel lifts

• Modify footwear

• Custom orthotics

• Night splints

• PT is a major key

Rarely

• Surgical debridement

Physical Therapy for AchillesAlfredson H, Pietilä T, Jonsson P, et al. Am J Sports Med, 1998;

26:3: 360-366.

• RCT – eccentric exercises (3 x 15 reps, 2 times/day, 7 days a week x 12 wks)

• Results: Significant difference in pain levels VAS 81.2 mm (+/- 18) to 4.8 mm (+/- 6.5) in 12 weeks

• 81% eccentric satisfied vs 38% concentric satisfied

Eccentric Drop program Terminology

• Tendinopathy –“tendon injury that originates from intrinsic and extrinsic etiological factors”

• Usually not tendinitis

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Classification of Tendon Disorders(Modified from Khan et al. 1999, Clancy 1990)

Pathologic Dx Macroscopic Histopathologic

Tendinosis Intratendinous degeneration

Disorganized collagen, mucoid degen

Tendinitis Degeneration with inflammatory repair response

Fibroblasts, hemorrhage, granulation tissue

Paratenonitis Inflammation of paratenon only

Mucoid degen. if areolar tissue, fibrinous exudate

Paratenonitis with tendinosis

As above As above

Where does the injury occur?

Insertional• Occurs at

insertions near the joint

• Joint sideTears• At the musculo-

tendinous junction• Areas of friction

3 Basic P/E findings for tendinopathy

1. Tenderness on direct palpation 2. Reproduction of pain with resisted

contraction (eccentric loading)3. Reproduction of pain with passive

stretch

Tendon Healing

• requires around 100 days to synthesize collagen

Mild – 2 to 4 weeksModerate – 4 to 6 weeksSevere – 6 to 12 weeks or longer

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Physical therapy for tendons

Stretching• Improves pain and ROM

Strengthening – eccentric loading• Mechanical loading accelerates tenocyte

metabolism

Modalities• Ultrasound and laser increase collagen

synthesis in fibroblasts in animals

Anti-Inflammatory?

• Little evidence to support use of NSAIDs in management

• Good Analgesic

• Steroid injection?• Needle tenotomy?

How do you exam for lateral epicondylosis ?

Patellofemoral Pain (PFP)

• “Runner’s Knee”• Multifactorial

• Too tight?• Too loose?

• Need good muscle balance

• Good flexibility

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Novel MRI Techniques

• 3T MRI provides a higher signal-to-noise ratio and better spatial and spectral resolution

• T1ρ spin-lattice relaxation reflect proteoglycan content

• T2 reflect collagen matrix orientation

(a) a healthy volunteer, male, 30; T1ρ = 40.0511.43 ms

(b) a patient with early OA (post‐traumatic OA), female, 27. T1ρ = 50.5619.26 ms

Li et al. Magn Reson Med, 2005.

Patellar Tilt

• N=17 18-45 y.o. with anterior knee pain, patella tilt, no X-ray osteoarthritis

• T1ρ lateral facets were elevated in PF patients vs. controls (45.95ms +/- 4.87 vs 40.60ms +/- 2.81, p=0.01)

• No difference medial facets

• Mean T1ρ values of the whole patella of PF patients correlated to degree of patellar tilt (r=0.74)

Thullier et al, AAOS abstract, 2012

Gluteus Maximus – the Running Muscle?

• Gluteus maximus –walking and standing have little EMG activity

• EMG studies show more active firing before heel strike

• GM utilized to stabilize the trunk against flexion (forward pitch rate is negative)

• GM most active during running and climbing

Lieberman et al., J Experimental Biol, 2006

Gluteus Maximus – the Running Muscle?

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Single leg squat Risk Factors for PFP

• Muscle imbalances– Vastus medialisweakness

– Hip abduction weakness

– Hamstring tightness

• Cavus feet

• Foot pronation

• Increased Q angle

Fields, Curr Sports Med Report, 2011

Treatment of Patellofemoral Pain

• Good evidence for open‐ and closed‐chain rehabilitation programs

• Control motion in the frontal and the traverse planes

• Include activation and strengthening of hip abductors, external rotators and extensors

• Maintain stable patellar tracking

• Physical therapy and orthotics show benefits for pain reduction

Shoes or No shoes ?

• Heel strike causes a force impact Saw-toothed force profile with High rate of loading 400-500 bw/sec

• Forefoot striking reduces the peak impact force

Lieberman et al, Nature, 2010

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Approach to Overuse Injuries

1. Mechanism of Injury / Pain

2. Location

3. Type of tissue

4. Identify risk factors

5. Education/Modifications to reduce overuse activity

Concussions

Credit: Carlin Senter, MD and Elise Hammond, ATC

UCSF Department of Orthopaedics

Bay Area Concussion and Brain Injury Program at UCSF

A collaboration between UCSF Medical Center, BenioffChildren’s Hospital, and San Francisco General Hospital

Concussions are common

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Concussions are common 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.

We Miss Concussions Concussion Definition

• Type of mild traumatic brain injury

• Blow to head, neck, body force to head.

• Neurologic impairment within 48 hours of trauma.

• Symptoms usually resolve in 1‐2 weeks

spontaneously but in some cases can be prolonged.

• May or may not include loss of consciousness.

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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.

Pathophysiology: Acute neurometabolic cascade

Force to brain

Ion fluxes; vasocon‐striction

Need glucose but less blood

flow

Energy crisis

Giza CC and Hovda DA, J of Athletic Training, 2001.Vespa et al, J Cerebral Blood Flow and Metabolism, 2005.

Concussion clinic evaluation: symptom checklist

SYMPTOMS s/p 6d

Headache 5

“Pressure in Head” 3

Neck Pain 0

Nausea / Vomiting 0

Dizziness 2

Blurred Vision 0

Balance Problems 2

Sensitivity to Light 2

Sensitivity to Noise 1

Feeling Slowed Down 3

Feeling like “in a Fog” 0

SYMPTOMS s/p 6d

“Don’t Feel Right” 5

Difficulty Concentrating 3

Difficulty Remembering 3

Fatigue / Low Energy 2

Confusion 0

Drowsiness 2

Trouble Falling Asleep 0

More Emotional 0

Irritability 2

Sadness 0

Nervous / Anxious 0

TOTAL 35

Concussion evaluation: physical exam

• Normal neck exam

• Normal neurologic exam

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Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013 Apr;47(5):250‐8

Concussion Treatment

• Cognitive rest

• Physical rest

• Medication– Tylenol

– Ibuprofen after first 72 hours

• No driving

• No Etoh

Case 1

17 y/o high school lacrosse player presents to your office with a concussion. He is a senior and his last high school game is in 4 weeks. He has no history of concussion, depression, or anxiety.

What is the likelihood that he will be back to play in his last game?

A. High: 90% of sports concussion patients are better within 3 weeks of injury.

B. Moderate: 65% of sports concussion patients are better within 3 weeks of injury.

C. Low: 25% of sports concussion patients are better within 3 weeks of injury.

D. Zero: sports concussion patients should rest from contact for at least 4 weeks post injury.

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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

Symptom Resolution after Sport Concussion

• 50% recovered and returned to play in 1 week; 90% in 3 weeks (Collins et al. Neurosurgery, 2006.)

• 7‐10 days avg. symptom resolution. (3rd International Conference on Concussion in Sport (2008). Clin J Sport Med, 2009.)

• High schoolers take longer to recover based on neuropsychological testing compared to college athletes. (Field et al, J Pediatr, 2003.)

Case 2

16 y/o high school student presents to your office with concussion sustained 3 days ago during football. He reports headache, fogginess, and dizziness that is mild to moderate intensity at home but moderately severe at school. He is resting from sports.

What do you recommend he do with respect to school?

A. Continue school without adjustments.

B. Continue school but no test‐taking.

C. Attend ½ days of school for a week, no test‐taking.

D. Rest from school until can tolerate 1‐2 hours of work at home.

E. Rest completely from school for a week.

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Return to Learn 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.

UCSF concussion clinic school note

Case 3

16 y/o high school student presents to your office Monday morning with concussion sustained playing soccer 3 days ago (Friday). She initially had headache, dizziness, and fogginess, but those symptoms resolved yesterday. She is now asymptomatic with a normal neurologic exam. She has no deficits on balance testing. She has no deficits on memory testing.

A. Today (Monday)

B. Tomorrow (Tuesday)

C. In 2 days (Thursday)

D. 1 week post injury (Saturday)

E. 2 weeks post injury

Assuming she remains asymptomatic, when would you clear her to return to

full contact soccer games?

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Concussion Legislation

• 50 states have adopted youth concussion laws

• California: education code 49475 (effective 1/2012)

1. 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

Concussion legislation

• California Assembly Bill 2127 (in effect 1/2015)

– Adds to AB 25

• FB full‐contact practice limits:

– No more than 2/week during preseason and season

– These practices cannot exceed 90 minutes

– No full‐contact in off‐season

• Once clear must follow gradual return to play protocol of at least 7 days under supervision of licensed provider

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.

Tuesday

Thursday

Wed

nesday

Friday Sa

turday

Return to play activity examplesStep Objective Activities

1 Recovery No activity

2 Increase heart rate Walking, swimming, or stationary bike. < 70% max heart rate. No weights.

3 Add movement Skating drills in hockey, running drills in soccer. No head impact activities.

4 Add coordination and cognitive load

More complex drills (passing). Can start weights.

5 Restore confidence and assess functional skills by coaching staff

Full‐contact practice

6 Normal game play


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Case 3

The student athlete follows up with you as scheduled in the office on Thursday to consider full contact clearance for Friday. She did 1 hour of high intensity non contact training earlier Thursday afternoon. She felt good except for a very mild headache during the sprinting workouts. The headache is now gone. Her neurologic exam, balance testing, and memory testing is normal.




Game play



Clinician clearance

Asymptomatic


Tuesday

Thursday

Wed

nesday

What do you do next?

A. Clear her for full contact practice on Friday followed by full contact game on Saturday.

B. Have her return to sport specific activity on Friday, then do non contact training Saturday and see you next week to consider full clearance.

C. Recommend rest from sports over the weekend, follow up with you next week.

D. Recommend rest from sports for one week, follow up with you in 2 weeks.




Game play



Clinician clearance

Asymptomatic


Tuesday

Thursday

Wed

nesday

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Symptoms during return to play

• If symptomatic during a step of the return to play protocol…

– Stop activity

– Rest until symptoms resolve, at least 24 hours.

– Resume return to play protocol at the step where athlete was last asymptomatic


Case 4

30 y/o recreational rugby player comes to your office with her 5th lifetime concussion. She suffered this most recent injury when she took a relatively insignificant hit to the body during a game. She immediately had headache, photophobia, nausea and came out of play. Her 4th concussion led to headaches x 6 months and interfered with her ability to do her job. She recovered 3 months ago from that injury.

Should she retire from rugby?

A. Yes. An athlete with 3 concussions or more should no longer play contact sports.

B. Yes. She likely has early onset dementia and should stop playing contact sports.

C. Yes. She is showing a decreased threshold for injury with increased severity of injury.

D. No. She can return as long as she wears a rugby scrum cap for protection.

E. No. She can return as long as she plays a lower risk position.

Is Concussion Really a “Mild” Traumatic Brain Injury?

http://www.bu.edu/cte/about/what‐is‐cte/

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Chronic traumatic encephalopathy

• Athletes and military personnel

• Chronic, progressive depression, cognitive impairment, aggression

• Diagnosed at autopsy: tau protein deposition

• Difficult to draw causality – no prospective data yet

• Concerning association between professional sports participation and long term neurologic/psychological problems

Gardner A et al. Chronic traumatic encephalopathy in sport: a systematic review. Br J Sports Med. 2013 Jun 26.

Randolph C. Is chronic traumatic encephalopathy a real disease? Current Sports Med Review, 2014.

How Many Concussions is Too Many?

• Individualized to athlete.

• Concussion hx.– Number.

– Less force.

– More frequent.

– Increased severity of sxs

– Increased duration of sxs.

– Age: possibly more consequences if younger at

time of concussion.

Keys to Managing Sports Concussion in 2015

• Treatment is rest.

• Gradual return to learn.

• Gradual return to play.

• Note for school and sports each visit.

• Monitor for repeat injury.

• No recommended protective gear

• Association between concussion and dementia (causality not proven)

• Treat each case individually.

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