Delaware Sports Medicine Pearls from a 30-Year Experience Michael - PowerPoint PPT Presentation

Delaware Sports Medicine Pearls from a 30-Year Experience Michael J. Axe, M.D. Partner, First State Orthopaedics Professor, University of Delaware Chair, SMAC of DIAA

Pearls (aka Axe-isms ) • Necessities – Critical to patient outcome • Niceties – May improve performance or healing time

AXE-ISMS Axisms 1) Be a Splitter 2) Educate your colleagues 3) Educate and respect your patients 4) Document your findings 5) Happiness is founded on Good Rehabilitation 6) Univ. of Delaware PT department is a great resource 7) Research is hard work 8) Safe return to play needs guidelines 9) Be active in your “communities” 10) Recycle Durable Medical Goods

Be a splitter ” You’d expect this from an Axe! “ Accurate Diagnosis  Specific Grade Grade - Treatment - Prognosis - Communication

Effusion Grades: modified sweep test • Trace: small fluid wave with superior pouch compression • +1: larger fluid wave with superior pouch compression • +2: fluid wave spontaneously returns • +3: too much to milk into pouch In rehab +1 or less – OK to progress Sturgill et al. JOSPT 2011

AXE-ISM: Educate your colleagues Wrong views = repeat X-ray/annoyed patient Hurts so Good, Hurts so Bad NSAIDS – Dose to Size Injections are worth it (good care and good $)

AXE- ISM “ Wrong views = repeat X-ray/annoyed patient ” • Shoulder series • Wrong views – A/P IR – A/P ER • Best views – A/P – Axillary lateral – Outlet

AXE- ISM “ Wrong views = repeat X- ray/annoyed patient” • Knee series • Wrong views – A/P non-weight bearing – A/P weight bearing straight knee • Best views – P/A weight bearing bent knee (20 degrees) – Sunrise (patella) – Lateral bent knee (30 degrees)

MRI/CTScan • Need contrast • r/o – Loose body – SLAP – Redo rotator cuff – Redo ligament repair

AXE-ISM “Hurts so Good, Hurts so Bad” Bad Good During exercise Post Exercise Sudden Onset Gradual Onset Stabbing Knife-Like Pain Dull Exercise Shut Down Generalized Altered Mechanics Kink Loss of Breath Works out with motion Pool, AI, Rest = NO HELP Tired arm NOT Dead arm Sx’s  with Rest & warm up Night pain

Dose of NSAIDS • 2 weeks @ max dose • Continue for one week more than you’re sore • Many different families • Dose dependent on size of patient – Less than 150 lbs – Less than 200 lbs – Less than 250 lbs • Acute vs Chronic

Additional Anti-inflammatory Steroid Dose Pack • Prednisone – 60 mg daily x 5 days – take with largest meal • Indications – Bee sting reaction – asthma – acute inflammation Vitamin E 1600 units

AXE-ISM “Injections are worth it” Spraying is fundamental Knees are easy Subacromial injections are not hard Tennis elbow hurts Ankles are the future Small joints have small spaces Wet joints/Dry joints Aspirations big needle big syringe

Injections • Repeat injections (2-4) • Pseudo-septic reactions “Shot Clinic” – Treatment algorithm

Spraying is fundamental Make your mark

Knee injections are easy Dr. Scott Dye Aspirations are not so easy! Ultrasound?

Subacromial injections are not hard • Provocative reduction

Wet joints/Dry joints Lubricants for ‘Dry Joints’ • Tin Man Therapy – 3 in one for the dry joint • Wet joints – get dry 1 st if possible

Knee Aspiration • Uncontrolled Pressure Pain • < 90 degrees flexion • > 5 degrees lack of full extension • Unable to initiate SLR 18 gauge Needle; 50 cc syringe

AXE-ISM: Educate your patients electronically! • The wall does it all…

Number One: When can I ...Drive? • What do the data say? • Gotlin and colleagues ( Arch Phys Med Rehabil 2000, Arthroscopy 2000) – Brake reaction time normal 4-6 weeks after right ACL • Nguyen and colleagues (Knee Surg Sports Traumatol Arthrosc 2000) – Reaction time normal 6 weeks after right ACL – Sit-to-stand 6 in 10 sec – Step test 15 in 10 sec - useful

AXE-ISM: Happiness is founded on Good Rehabilitation “Your PT colleague is your best friend” Goals: BE FUNCTIONAL! A. Control Pain and Swelling B. Restore ROM C. Restore Strength

Good Rehabilitation “The patient is not always right” 1600 1400 1200 1000 Force (N) 800 600 400 200 0 0 500 1000 1500 2000 2500 Time (ms)

Necessity - Nicety • NMES can be used at any time during the rehabilitation phase after knee surgery • NMES is superior to voluntary exercise in increasing isometric strength of knee extensors after ACL reconstruction* • Need a STRONG stimulator *Snyder-Mackler et al J Bone Joint Surg 1995 Fitzgerald et al JOSPT 2005

Good Rehabilitation Necessities A. Understanding of soft tissue healing & fixation techniques B. Diagnosis Driven Programs C. Objective Criteria for Progression D. Significant “Hands On Time” per visit E. Office call for variance F. Appropriate Home Exercise Program (HEP) G. Discharge criteria with outcomes

Good Rehabilitation PT understands soft tissue healing & fixation techniques Rehab Modified Surgery Surgery Modified Rehab Surgeon attempts Rigid Fixation Tissue issue Screws Stitches Fixation: Race between healing vs. fixation failure

Good Rehabilitation Diagnosis Driven Programs – Protocols: A Good Start – Programs • Functional – Simulates the activity • Practical - < 60 minutes • Progressive

Functional Progression Start Lateral ankle sprain Finish

Good Rehabilitation Objective Criteria for Progression • Don’t forget Healing Principles • Soreness Rules • Effusion testing

Objective Criteria for Progression SORENESS RULES (1-5) Criterion Action 1. Soreness during 2 days off, drop down 1 step warm-up that continues 2. Soreness during Stay at step that led to warm-up that goes soreness away

Objective Criteria for Progression SORENESS RULES 2 days off, drop down 1 step 3. Soreness during warm-up that goes away but redevelops during session 1 day off, do not advance program to the next step 4. Soreness the day after lifting (Not muscle soreness) Advance one step per week 5. No Soreness or as instructed by healthcare professional

Good Rehabilitation Significant “Hands On Time” • Use the Gym if that’s all they need Visits/wk Reason 4-5 Swelling &/or pain control Joint Mobilization 3 ROM, Pain control, Strengthening/early phase 2 Strengthening / late phase Functional advancement

Good Rehabilitation Office call for Variance #1 Temp increase with an angry wound • Failure to Progress – “The 3 S’s” – Re-evaluation ( S ee) – Subspecialty consultation (Send) – Injections ( S hoot)

Good Rehabilitation Office call for Variance • Injection shoulder  morbidity 50% – • Provocative Reduction – Hurt – Help

Good Rehabilitation Home Exercise Program requires 3 visits • Patient Understanding 1 – 60% 2 – 80% 3 – 90% • Patient Compliance Feels Better -  compliance –

Discharge Criteria & Outcomes Guidelines - Dx / # of visits Community Tennis elbow 8*-16 10-12 Rot. Cuff Tendinitis (no tear) 8*-15 10-12 Patellofemoral (no strength deficits) 8 8-12 Quadriceps Tendinitis 10 10-12 Patellar Tendinitis 14 10-12 Hamstring Strain (no rent) 8 6-12 (sport dependent) Postop Meniscectomy 8 6-8 16 ± 5 Postop ACL (isolated) 20 Achilles Tendinitis 8 10-12 Grade II lateral ankle sprain 12 6-8 visits Plantar Fasciitis 10*-20 10-12 (could be a lot) * - injection

AXE-ISM “UDPT is a Great resource” Ask the N.I.H. • Over $ 20 million to investigate rehab after… Total Knee & Hip ACL 1) Healthy people with Achilles & Patellar • Acute ACL injured isolated knee OA tendinopathy • ACLR who want to 2) Preoperative and postop 1. Patients with unilateral TKA and THA return to sports tendinopathy 3) Ages 50-85 y/o “We’re #2!” 4) No diabetes

AXE-ISM: Document your findings “It takes time” • Clinical • Operative • Make it prospective! “Retrospective research is the worst!”

AXE-ISM “Research is Hard Work Especially in Private Practice” Sustained commitment – for more than 30 years

How to get your research projects started (Even if you’re in Private Practice) Michael J. Axe, MD Lynn Snyder-Mackler, PT, ScD, FAPTA AOSSM Research Symposium Quebec City 2004 and Keystone 2005

Reasons to do research • Acceptance to Fellowship /Residency/Med School • Tenure and Promotion • Notoriety- practice builder • BURNING QUESTIONS

Absolutes for success I. Question must be answerable Best: yes or no II. Team – Necessary Skills III. Funding IV. Adequate research subjects V. Team time availability VI. Site with all the necessary equipment

The Question Hypothesis Driven

Team – Necessary Members for Success • Dreamer • Logistics/Design • Conscience • Analyst • Worker Bees • Manager/ Captain

Team - Dreamer • Feels the fire • The energy • Usually their question

Team- Logistics/Designer • Materials and Methods

Team – Conscience • Stay on mission • Keep the project important • And (clinically) relevant Resist the urge!