Sports Medicine

From Clinical Pediatrics, presented by the American Academy of Pediatrics, California Chapter 2

James G. Garrick, MD, Professor of Pediatrics, University of California,
San Francisco, School of Medicine

Educational Objectives

The goal of this program is to improve the diagnosis and management of sports injuries. After hearing and assimilat­ing this program, the clinician will be better able to:

1.   Recognize signs and symptoms of the most common injuries of the knee, ankle, thigh, wrist, and shoulder.

2.   Determine when and how to aspirate fluid from a joint.

3.   Properly apply ice and compression to treat ankle sprains and patellar bursitis.

4.   Discriminate wrist fractures from sprains, and treat appropriately.

5.   Diagnose and manage overuse injuries, including patellofemoral dysfunction.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any per­sonal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, Dr. Garrick and the planning committee reported nothing to disclose.

Acknowledgements

Dr. Garrick was recorded at Clinical Pediatrics, held February 12–15, 2009, in Palm Springs, CA, and sponsored by the American Academy of Pediatrics, California Chapter 2. The Audio-Digest Foundation thanks Dr. Garrick and AAP California Chapter 2 for their cooperation in the production of this program.

Sports Medicine Pearls

Fluid in knee: amount and rate of accumulation of fluid in joint correlates with pain; aspiration performed to relive pain; if blood obtained, place aspirate in basin and examine after 2 to 3 min for fat globules; presence of fat glob­ules (from marrow) indicates intra-articular fracture, and orthopedic surgery required

Ankle sprains: most common acute musculoskeletal injury in United States; difficult to find individuals who have not had ankle sprain to participate in studies; traditional initial management includes rest, ice, compression, and el­evation; reduce swelling; traditional pressure bandage may not apply compression where swelling occurs; to pre­vent loss of motion, strength, and subsequent re-injury, fill in hollow areas in contour of ankle using, eg, surgical pads, folded sock, or felt cut into horseshoe shape wrapped around malleoli; subsequently apply elastic bandage or stockinette to provide focal compression; ice  —  to prevent blisters, apply single layer of bandage next to skin be­fore using ice under compression; compression more beneficial than ice; exercise and rehabilitation  —  after 24 to 36 hr of treatment, encourage patient to walk slowly with ankle brace or AirCast to decrease chance of second an­kle sprain; variety of designs of ankle braces equally effective; simpler and easier to use types preferable; contrast baths  —  helpful for cases with severe swelling; alternate soaking for 4 min in warm (100°F) water bath while writ­ing alphabet with big toe, with 1 min in ice water; repeat 4 times; patient should wear brace for remainder of sports season and perform home exercise program provided by physical therapist, including resisted exercise and range of motion

Thigh contusion: common in football, basketball, and hockey; if patient continues to play after injury, muscle may go into spasm; danger of developing myositis ossificans where part of muscle coming off femur forms bone; complication usually occurs as result of second injury or too vigorous passive stretching; easily mistaken for os­teogenic sarcoma on biopsy; bone eventually resorbs, but prevention easier

Treatment: immediate immobilization with maximum flexion of knee for 24 hr; most patients return to athletic par­ticipation in 7 to 10 days

Shoulder dislocations: second most common type of dislocation (after fingers) in sports; usually anterior/inferior; common causes include receiving blow to arm while arm externally rotated or abducted, or falling on out­stretched arm

Signs: patient carries arm in neutral position with other hand, resists rotation of arm, and shoulder appears different

Treatment: make sure axillary nerve intact (provides sensation and motor impulses to lateral deltoid muscle) by testing activation of muscle or sensation over middle of deltoid; x-ray image not necessary; reduction  —  patient clasps hands, places knee behind hands, and leans backward; procedure associated with 95% rate of success without medication when done in £1 hr, 65% if done in £6 hr

Prepatellar bursitis: may result from falling on knee; sometimes recurrent; characterized by focal swelling in ante­rior aspect of knee; associated with variable levels of pain; swelling prominent, with discrete margins, when knee flexed (similar appearance for analogous injury in elbow, ie, olecranon bursitis)

Treatment: initially, apply ice and compression wrap; if fluid remains, consider aspirating; if no evidence of infec­tion, administer cortisone injection later; if possibility of infection, obtain x-ray; aspiration  — use large needle; do not attempt to insert needle in bursa at largest part of swelling (risk of introducing microorganisms from skin into bursa); instead, using local anesthetic, enter skin »1 in from bursa, tunnel under skin, and enter bursa from side; administer long-acting steroid and apply compression wrap for 3 to 4 days

Knee injuries (general): patellofemoral dysfunction (chondromalacia patella) most common; symptoms  —pain in front of knee while going up and down stairs, walking, or during or after sitting; often, injury occurred several months before presentation

Treatment: apply splint and knee immobilizer with knee flexed »5° to make patient comfortable; many patients ex­perience tendinitis in hamstrings because of strain of holding knee partially flexed without brace; begin exercise program after 2 to 3 days (eg, cycling and weight-lifting); do not immobilize knees with ligament injuries

Wrist injuries: falls on outstretched hands usually cause fracture of carpal scaphoid; symptoms include swelling and pain in wrist and at base of thumb; ³33% of carpal scaphoid or navicular fractures not detected via initial x-ray; fracture becomes visible on x-ray 3 to 4 wk later; if wrist fracture diagnosed, patient must wear navicular cast; to distinguish between sprain and fracture before applying cast, apply gymnast’s wrist splint and obtain technetium bone image after 2 days

Office Management of Overuse Injuries

Overuse injuries: eg, tennis elbow, runner’s knee, gymnast’s wrist, golfer’s elbow and back

Finding cause: crucial to prevent recurrence; obtain history to determine timing of injury; overuse injuries have gradual onset (ie, patients cannot describe exact time of onset)

Patient education: to prevent recurrence, emphasize need for exercise programs and strength training, even after pain resolved

Patient history: temporal relationship of pain to activity  — at first, pain occurs after activity; over time, pain may occur during activity; finally, pain prevents patient from performing activity; exact location of pain  —  in knee or shoulder overuse injury, pain often diffuse; if patient can specifically point to pain, localized tendinitis or stress fracture likely

Findings on examination: loss of strength and muscle mass rapidly become apparent in all patients in £5 days; loss of motion and flexibility; patients may have tenderness, swelling, and crepitation; “snowball” crepitation (squeaking) diagnostic for acute fulminant tendinitis and indicates need for steroid (eg, oral prednisone for 4 days)

Management: avoid referring patient to orthopedic surgeon (no surgical options available), unless all other treat­ments fail; recommend treatment regimen of medication, rest, and rehabilitation program; ancillary tests not needed because all overuse injuries respond to same simple therapeutic regimen

Referrals: refer patients with abrupt loss of motion (locking), sudden significant swelling that restricts motion, lax­ity or instability, or neurologic symptoms (eg, distal numbness and tingling), and patients in whom treatment has failed, or when diagnosis unclear

Medications: nonsteroidal anti-inflammatory drugs  —good analgesic properties; studies show ibuprofen comparable in efficacy to hydrocodone and acetaminophen (eg, Vicodin); prescribe ibuprofen or naproxen in anti-inflammatory doses (double over-the-counter dosage) for 7 to 10 days with no refills; however, avoid giving such high doses that injury worsens because symptoms masked; oral steroids  —speaker recommends prednisone “burst” (20 mg bid for 4 days); patients feel relief after 24 to 36 hr; however, emphasize that injury not healed, although pain relieved; steroid injections  —  avoid using in weight-bearing joints, especially in young people, because it impedes repara­tive process in joint; complications include local depigmentation and atrophy of subcutaneous fat

Rest: identify activities that cause pain and advise patients to avoid those activities; maintain conditioning (eg, ex­ercise cycle; cross-country ski, step, or rowing machines; elliptical trainer) but caution patient about risk for strain of hip and knee, and pain after exercising; instruct patients on exercise cycle to start at zero resistance for 20 min, then increase resistance slowly (1 U/day); stop increasing resistance when patient experiences discom­fort after exercise

Rehabilitation: goal to regain strength and endurance (flexibility improves automatically); according to Centers for Disease Control and Prevention (CDC), no evidence that stretching before exercise reduces risk for injury; also, no evidence that deep tissue massage or active-release therapy beneficial for tendinitis; all patients with overuse injuries require rehabilitation programs; simply resuming symmetric activity not sufficient to restore strength to injured side; no benefit in exercising while injury painful; patients do not heal while symptomatic

Additional testing: x-ray, computed tomography (CT), bone imaging, magnetic resonance imaging (MRI), com­plete blood cell count (CBC), and culture unnecessary

Patellofemoral dysfunction (PFD): most common overuse injury; can occur with any activity, but especially seen in running and jumping; more common in women

History: gradual onset; may follow injury; pain most often medial; may produce swelling if problem prolonged; pain experienced while squatting, climbing stairs, sitting for long periods, and “gelling” (stiffness in knee) after sitting; locking or “giving way” may occur if leg very weak

Examination: findings include atrophy and decreased tone of quadriceps, effusion (possible but not necessary for diagnosis), and loss of motion; vastus medialis muscle  —  controls tracking of patella; weakness causes displace­ment of knee; important that patient recognize weakness of muscle as cause of injury to motivate them to per­form exercises

Other tests: x-ray and MRI not necessary

Treatment: avoid specific painful activities; rehabilitate vastus medialis with exercise (eg, isometrics, cycling, sin­gle-leg presses [never flex knee >90°, perform negative phase 3-times more slowly]); use patellar stabilizing sleeve to relieve pain; muscle stimulator to cause contraction of muscle useful for patients who cannot perform exercises; perform single-leg squats (leaning on wall with heels away from wall if necessary) only to 90° flexion, and gradually move heels closer to wall; do not use knee extension machines; speaker prefers exercise cycles

Case example: girl, 14 yr of age; cross-country runner; experienced diffuse pain in knee after workouts; pain wors­ened enough to interfere with daily living; history of severe ankle sprain previous spring; diffuse pain indicates ab­sence of patellar tendinitis, Osgood-Schlatter disease, or iliotibial (IT)-band tendinitis; x-ray optional (to rule out osteochondritis dissecans); probable diagnosis patellofemoral dysfunction

Suggested Reading

Abbassian A, Thomas R: Ankle ligament injuries. Br J Hosp Med (Lond) 69:339, 2008; Bhave A, Baker E: Pre­scribing quality patellofemoral rehabilitation before advocating operative care. Orthop Clin North Am 39:275, 2008; Brophy RH, Marx RG: The treatment of traumatic anterior instability of the shoulder: nonoperative and surgical treatment. Arthroscopy 25:298, 2009; Collins CL, Comstock RD: Epidemiological features of high school baseball injuries  in the United States 2005-2007. Pediatrics 121:1181, 2008; Cox CL, Kuhn JE: Operative versus nonopera­tive treatment of acute shoulder dislocation in the athlete. Curr Sports Med Rep 7:263, 2008; Dopirak RM et al: The medial patellofemoral ligament. Orthopedics 31:331, 2008; Hertel J: Immobilization for acute severe ankle sprain. Lancet 373:524, 2009; Huckstadt et al: Pediatric fractures of the carpal scaphoid: a retrospective clinical and radio­logical study. J Ped Orthop 27:447, 2007; Kamper L, Haage P: Images in clinical medicine. Prepatellar bursitis. N Engl J Med 539:2366, 2008; Lamb SE et al: Mechanical supports for acute, severe ankle sprain: a pragmatic, multi­centre, randomized controlled trial. Lancet 373:575, 2009; Martin B: Ankle sprain complications: MRI evaluation. Clin Podiatr Med Surg 25:203, 2008; Moorjani GR et al: Patient pain and tissue trauma during syringe procedures: a randomized controlled trial. J Rheumatol 35:1124, 2008; Patel R, Haddad F: Joint and soft tissue aspiration and injection. Br J Hosp Med (Lond) 67:M44, 2006; Rees J et al: Management of Tendinopathy. Am J Sports Med Feb 5, 2009 [Epub ahead of print]; Wang RY et al: The recognition and treatment of first-time dhoulder dislocation in ac­tive individuals. J Orthop Sports Phys Ther 39:118, 2009.