Disclosures UCSF Controversies in Womens Health 2016 December 8, - PDF document

Disclosures UCSF Controversies in Women’s Health 2016 December 8, 2016 I have nothing to disclose Common Activity-Related Conditions in Women Cindy J. Chang M.D. UCSF Primary Care Sports Medicine Associate Clinical Professor of Orthopaedics and Family and Community Medicine Objectives 17 pages long! Discuss common n activity-related conditions in women Review treatment and n prevention plans for these conditions Identify possible areas n of controversy in the diagnosis and management of these conditions

Activity-Related Conditions Common Reasons Not To Exercise Musculoskeletal Activity-Related n I don ’ t have the I njuries Medical Conditions time Anterior Cruciate Female Athlete Triad n I don ’ t like to sweat n n Ligament (ACL) u Amenorrhea n I ’ ll look silly injuries F Menstrual dysfunction n I don ’ t know what u Disordered Eating Patellofemoral n to do F Low energy availability Dysfunction (PFD) u Osteoporosis Greater Trochanteric n It ’ s not important n F Low bone density Pain Syndrome n It hurts Stress Fractures n n I will get hurt History, History, History! Important Points re: MS Injuries Age, occupation, etc. 1. With a good history…you should arrive at the correct Date of injury/symptom onset 2. n diagnosis 90% of the time Injury Mechanism: 3. Or at least a confident top 3 differential! Acute: pop, ability to continue activity a.  Chronic/Overuse: precipitating activity b. With a good history, and comfortable knowledge of Swelling: location and timing 4. n basic anatomy…it will make your exam focused, Symptoms: Mechanical/Other 5. quick and efficient Locking, clicking, grinding, weakness, instability a. u And give you more time to chart… Symptoms: Pain/Numbness/Tingling 6. Location - Point to where it is a. With a good history, and comfortable knowledge of Radiation - come from or go anywhere else b. n basic anatomy, you will not need to palpate until the Type - burning, sharp, dull, achy, constant, at night, c. END of the exam… w/ activity or position, Grade pain u Or you risk your patient not letting you finish the Modifying/Other Factors 7. exam! Better/worse, previous injury/surgery, any red flags a.

Knee Injury Which next question would be the least valuable in terms of determining the diagnosis? 30 yo female playing in family Thanksgiving Day n touch football game Tackled by her brother and her knee twisted under n her 1. How long did it take before it swelled? Now seeing you 1 week later and she is using an n ACE wrap and borrowed cane 2. Were you able to continue playing? 3. Does your knee “give way”? 4. Did you feel a pop? Acute Knee Injury Acute Knee Injury 30 yo female playing in family Thanksgiving Day Differential Diagnosis n n touch football game u Ligament tear Tackled by her brother and she felt a pop as her F ACL tear n knee twisted under her F MCL tear Hard to put weight on leg and was unable to F Less likely LCL tear, PCL tear n continue playing u Meniscus tear The knee swelled “like a melon” within 2 hours u Patellar dislocation n despite ice u Bone contusion/Fracture Her knee shifts when she puts more weight on it n u Tendon rupture Now seeing you 1 week later and using an ACE n u Chondral injury wrap and borrowed cane

Knee Anatomy Anterior Knee Lateral Knee Medial Knee

Knee – Posterior Acute Knee Injury n Physical Exam u + Effusion u Ligament stability F + Lachman F - Posterior drawer Anatomical Differences ACL Tear

Hormonal Factors Conditioning and Experience n No difference in conditioning n No relationship of injury rate to NCAA division n No difference in prior organized sport experience u ? u ? Neuromuscular Factors Muscle Strength and Recruitment n Female athletes: u Land with greater total valgus motion u Weaker hip extensors u Less hamstring activation u Significantly less muscle strength and endurance F Even when corrected for body weight u Chappell et al 2002

“ Take 3 to Save the Knee ” n Accentuate balanced body motion n Control limb rotation n Land with bent knee and hip n PEP (Prevent injury and Enhance Performance) u 2-3x/week for 15 min u 88% decrease in ACL tears u Incidence rate of 1.7 in control /0.2 in enrolled Non-Traumatic Knee Injury Patellofemoral Dysfunction Will point to kneecap 40 yo female joined a gym in January with her n n region partner Pain associated with Began working with a personal trainer and they n n running, lunging, squats started a program of Olympic lifting (squatting, Pain with sitting for cleans) and plyometrics (box jumps) n prolonged period After 2 weeks she began having left knee pain after n Pain going down stairs workouts but continued training n may be worse than up Now seeing you 2 weeks later because now it hurts n stairs during training and even with walking, especially on Soft tissue swelling often the stairs n described as puffiness Often feels “stuck” and clicks n

Patellofemoral Dysfunction Patellofemoral Dysfunction Treatment Positive patellar compression n Quadriceps strengthening n test u Straight leg raises Pain on palp of medial facet of n u Leg extensions patella Increased patellar mobility n Patellofemoral Dysfunction Patellofemoral Dysfunction Thomas test to evaluate tight n hip flexors, quads, ITB

Patellofemoral Dysfunction Patellofemoral Dysfunction n Evaluate feet as well Single Leg Squat to evaluate for n weak quads, gluts Patellofemoral Dysfunction Hip Pain Treatment Stretching to achieve biomechanical balance 50 year old female begins training for a half n n marathon with her daughter Strengthening of gluteus medius n She begins to experience hip pain Proper shoewear or support n n She comes in for “an injection” so she can continue Patellar knee bracing n n training The race is in one month n She points to her lateral hip as area of pain n

Greater Trochanteric Pain Greater Trochanteric Pain Syndrome Syndrome Knee Pain Greater Trochanteric Pain Syndrome 25 year old female training for her 10th half n marathon this year; this one she is running with her 50 yo mother to celebrate their birthdays She begins to experience knee pain when running n She comes in for “an injection”; it “has to be done n today” so she can continue training She had patellar tendinitis x 1 month and she just n resumed training 2 wks ago The race is in one month. She doesn’t want to n disappoint her mom or herself and “has to race” When you ask where she hurts, she points to her n lateral knee and patellar tendon but then also anterior hip, lateral hip, buttocks, groin

Which of the following is NOT Anatomy Anterior Hip an increased risk factor for a stress fracture in this patient? 1. If she is of Caucasian ethnicity 2. If she has oligomenorrhea 3. If she is a lacto-ovo vegetarian 4. If she has inadequate caloric intake 5. If she has rapidly increased the volume and intensity of training Imaging of the Hip Knee/Hip Pain • AP and frog pelvis Insidious onset of pain n • MRI of hip No history of trauma n u Her knee hurt first u Then 3 days ago maybe pulled a hip flexor from hill running? Improves with rest, worsens n with loading Location can be variable on any n given day + Hop test n + Fulcrum test n

Stress Fracture Management Additional Management… Site of Fx % healed at 2 - % healed at 1 - % healed at This 20 yo female n 4 w ks 2 m o. > 2 m o. u is of Caucasian ethnicity Tibia, prox 1/3 0 43 57 u has oligomenorrhea Tibia, mid 1/3 0 48 52 u is a recent vegen Tibia, dist 1/3 0 53 47 u often skips breakfast and delays dinner if it Fibula 7 75 18 interferes with training Metatarsals 20 57 23 u had rapidly increased the volume and intensity Sesamoids 0 0 100 of training after her patellar tendon injury to try Femur, shaft 7 7 86 to prepare for the race Femur, neck 0 0 100 Pelvis 0 29 75 What additional questions would be helpful in n Olecranon 0 0 100 terms of managing her stress fracture? Brukner P, Sports Med 1997 Female Athlete Triad What combination of questions would be most helpful in managing this 1997 injury? Her highest body weight at her current height, 1. and her pre-race meal? If ever had regular menses, and her lowest 2. body weight at her current height? Why become a vegan, and other stress 3. fractures? Other stress fractures, and her ideal weight? 4. Her post-race recovery food, and her weight 5. when she started her menses?

Female athlete triad Energy Balance 2007 Trend among athletes toward inadequate energy n u Healthy energy intake without the presence of a clinical eating u Suboptimal status disorder energy The imbalance of energy intake and energy availability OPTIMAL n u Low energy expenditure results in low energy availability HEALTH availability There may be nothing “left over” for other body with or u Healthy n functions without bones u Healthy eating d/o u Low bone menstrual density cycles PATHOLOGY u Irregular menses u Amenorrhea u Osteoporosis Energy Balance DSM-4 vs. DSM-5 Fem ale Athlete Triad RED-S Anorexia Nervosa (AN) : No longer requires n am enorrhea to be a diagnostic criterion Bulimia Nervosa (BN) : Reduces frequency of binge n eating and compensatory behaviors to once a w eek instead of twice weekly Binge Eating Disorder ( BED) now a separate n diagnosis Eating Disorder Not Otherwise Specified n ( EDNOS) has been rem oved u Other Specified Feeding or Eating Disorder (OSFED) u Unspecified Feeding or Eating Disorder (UFED)