6/23/2015 Hot Topics in Hot Topics in Sports Medicine 2015 Sports Medicine 2015 • Sports concussion – Diagnosis – Treatment • Knee pain due to osteoarthritis + meniscus tear – Exam – Treatment evidence Carlin Senter M.D. • Rotator cuff tears UCSF Internal Medicine and Orthopaedics – Physical examination evidence UCSF Advances in Internal Medicine Concussions are common US military and traumatic brain injury • 320,000 blast-related TBIs from wars in Iraq and Afghanistan (MacDonald CL et al. Detection of Blast-Related Traumatic Brain Injury in US Military Personnel, New England Journal of Medicine 2011.) • mTBI accounts for 80-90% of TBI in civilian and military populations (Levin HS and Diaz-Arrastia RR. Lancet Neurol 2015; 14: 506-17.) 1
6/23/2015 Concussion numbers increasing Concussion legislation • California: Education Code 49475 (effective 1/2012) 1. Student 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 Marin JR et al. Trends in visits for traumatic brain injury to emergency http://fuerzadesign.com/wp-content/uploads/2014/10/thumbnail-United-States.jpg departments in the United States. JAMA. 2014 May 14;311(18):1917-9. Case #1 Concussion definition • 40 y/o woman presents to your office for ER follow-up • Type of mild traumatic brain injury two days after bike accident. • Blow to head, neck, body � force to head • Slid out while crossing streetcar tracks on wet city • Rapid onset of neurologic impairment streets. • No loss of consciousness. • Symptoms usually resolve in weeks, spontaneously, • Taken by ambulance to ER. but in some cases can be prolonged. • Had trauma work-up including head CT (-). • May or may not include loss of consciousness. • Has headache, fatigue, dizziness, light sensitivity. • CT and MRI studies are normal Trouble staying focused at work, sleeping more than usual. • Normal neck and neurologic exam. Adapted from 4th International Conference on Concussion in Sport (2012). Br J Sport Med. 2
6/23/2015 Concussion symptoms Clinic concussion evaluation • History of injury Physical • PMHx ADHD, anxiety, depression, head injury • Clinical status: improving or Sleep Cognitive worsening since time of injury? • Neck and neurological exam Emotional http://www.cdc.gov/ncipc/tbi/Facts_for_Physicians_booklet.pdf. Accessed Nov. 9, 2008. How severe is my concussion? • Concussion grading is retrospective • Age > 60 • Decreased alertness after – Historically concussions were graded on the • GCS < 14 initially or < 15 initially lucid • High velocity injury (hit by sideline based on amnesia and LOC at time of two hours post injury • Vomiting more than once injury. car, fall from height) • Comorbid illness – American Academy of Neurology, 1997 • Seizure – Cantu, 2001 (cirrhosis, diabetes, • LOC – Studies have shown these factors not to be predictive immunosuppression) • Focal neuro deficit • Pregnancy of recovery. • Suspected skull fx • Anticoagulants • Only when the athlete recovers can you tell how • Severe headache severe the concussion was Adapted from Levin HS and Diaz-Arrastia RR. Lancet Neurol 2015; 14: 506-17, using NICE 2014 and 2008 American College of Emergency Physicians/US CDC http://thehoopla.wpengine.netdna-cdn.com/wp- policy statement. content/uploads/2012/10/rage-meter-1.jpg 3
6/23/2015 Symptom resolution Case #1 • 40 y/o woman presents to your office for ER follow-up • Athletes become asymptomatic in 1-2 weeks two days after bike accident. ( Williams RM et al. Sports Med. 2015 Mar 28.) • Slid out while crossing streetcar tracks on wet city • Recovery in athletes may be faster than in others streets. • No loss of consciousness. (Levin HS and Diaz-Arrastia RR. Lancet Neurol 2015; 14: 506-17.) • Taken by ambulance to ER. • Pre-existing neuropsychiatric disorder associated • Had trauma work-up including head CT (-). with symptoms > 3 months (Levin HS and Diaz-Arrastia RR. • Has headache, fatigue, dizziness, light sensitivity. Lancet Neurol 2015; 14: 506-17.) Trouble staying focused at work, sleeping more than usual. • Normal neck and neurologic exam. How would you treat this patient? Concussion treatment • Cognitive rest A. Order urgent head CT to rule out subtle • Physical rest post traumatic bleed, return to clinic • Medication after CT. 69% – Tylenol B. Rest from work and biking, return to – Ibuprofen after first 72 clinic 1 week. hours 18% • No driving C. Return to work but rest from biking, 14% 0% • No alcohol return to clinic in a month. Order urgent head CT to ... Rest from work and bikin.. Return to work and biking. Return to work but rest ... • Education D. Return to work and biking. 4
6/23/2015 Return to school/work progression Physical rest • Evidence sparse on benefit of rest Return to full • Management largely guided by expert opinion day of school. Return to ½ • No same-day return to play day of school. 30 min schoolwork at • Once concussion symptoms have resolved 15 min a time until cognitive can do 1-2 No school. activity at a hours. gradually return to play time. OK to do light reading, little bit TV, drawing, cooking as long as doesn’t worsen symptoms. http://www.chop.edu/service/concussion-care- for-kids/returning-to-school.html Return to play progression Concussion statement 2012 Clinician clearance Game play Full contact practice Non- Asymptomatic contact Sport training specific Light activity aerobic activity 2 nd International Conference on Concussion in Sport (2004). 2005 Br J Sport Med 39:196 . 5
6/23/2015 Case #2 Area of tenderness • 55 y/o man with medial-sided pain and swelling of the R knee for 6 weeks. • No locking, no instability • Exam: effusion, tender medial joint line and EFFUSION above/below medial joint line, (+) medial knee irritation with medial McMurray, (+) medial pain with squat and Thessaly, no ligamentous laxity • He brings with him x-rays and MRI for your review http://www.ski-injury.com/kneeanat.gif, Accessed 10/04/05. Accessed 10/4/05 Meniscus: McMurray Meniscus: Thessaly Sensitivity medial 65%, Specificity medial 93% Video used with permission from Anthony Luke, MD. Magee, DJ. Orthopaedic Physical Assessment, 5 th ed. 2008. 6
6/23/2015 Meniscus: squat 4 tests for meniscus tear 1. Isolated joint line tenderness 2. McMurray 3. Thessaly 4. Squat These tests not needed in patients with knee OA. Do these tests in patients < 50 with isolated joint line tenderness. Radiograph MRI - report • Menisci: complex degenerative tearing of the 3 views for knee pain – Weight bearing medial meniscus posterior horn and body. flexed PA (aka notch • Cruciate ligaments: intact view) • MCL/LCL: intact – Lateral of affected side • Extensor mechanism: intact – Sunrise or merchant • Cartilage and bone: moderate-grade cartilage view loss over the medial femoral condyle and medial tibial plateau http://nurse-practitioners-and-physician- assistants.advanceweb.com/Features/Artic les/Knee-Osteoarthritis.aspx 7
6/23/2015 Diagnosis? Initial treatment? A. Medial meniscus tear A. Refer for arthroscopic debridement of 88% meniscus tear and lavage B. ACL tear 77% B. Nonoperative knee OA program C. Moderate medial compartment osteoarthritis C. Refer for total knee arthroplasty D. Patellar dislocation 21% 10% 2% 0% 0% 0% E. Septic arthritis 2% Medial meniscus tear ACL tear Septic arthritis Patellar dislocation Medial meniscus tear a.. Moderate medial compa... F. Medial meniscus tear and moderate . . . . . . . e . . p h d A t c r i O a p o e e e c e s n medial compartment osteoarthritis o n k k r h e l a t v t r i o a t a t r r o r o e f p f r e o r n e f f e o e R N R Interventions • Control • Arthroscopic surgery – PT: 1 hour/week x 12 – Irrigation with saline – 1 or more of the weeks – Home ex program following: • Debridement or excision 2x/day – Instruction on ADLS of degenerative meniscus tears – Self management • Removal loose bodies, • 188 patients followed x 2 years arthritis education chondral flaps, bone spurs • Primary endpoint WOMAC score (knee pain + fxn) reading + videotape – Medical and physical – Medications (APAP, • Avg age 60, 2/3 female, BMI 31 therapy like controls NSAIDs, hyaluronic acid • Excluded bucket handle meniscus and severe injections) varus or valgus alignment Kirkley et al. A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee, NEJM, 2008. 8
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