(My) 2017 Top Sports Medicine Conditions in Women UCSF - PDF document

Disclosures None. (My) 2017 Top Sports Medicine Conditions in Women UCSF CME:Controversies in Womens Health Carlin Senter, MD Associate Professor Primary Care Sports Medicine UCSF Medicine and Orthopaedics Learning objectives Case #1 60 y/o woman presents with 3 months of medial knee pain. Upon completion of this session, participants should be able to: (+) swelling, and instability. No frank locking. Pain is worse 1. List 3 indications for knee arthroscopy with weight bearing. Better with rest, ice, and NSAIDs. She 2. List 5 treatment modalities for knee osteoarthritis brings a knee MRI for your review. 3. Name 2 conditions in which the shoulder has limited active and Exam: Neutral knee alignment when standing, tender medial passive range of motion joint line + medial femoral condyle + medial tibial plateau. 4. Define the female athlete triad Small effusion. ROM 0-120, limited by pain. Mild crepitus. (+) medial Mcmurray, medial knee pain with squat. No 5. Write an exercise prescription ligamentous laxity.

Case #1: MRI results Which of the following would you recommend?  Small effusion A. Refer for arthroscopic debridement of meniscus tear and lavage  Moderate chondrosis medial femoral condyle B. Nonoperative knee OA program and medial tibial plateau C.Refer for total knee replacement  Degenerative medial meniscus tear Case #1 Clinical criteria for diagnosis of knee OA 60 y/o woman presents with 3 months of medial knee pain. (+) swelling, and instability. No frank locking. Pain is worse with weight bearing. Better with rest, ice, and NSAIDs. She brings a knee MRI for your review. Exam: Neutral knee alignment when standing, tender medial joint line + medial femoral condyle + medial tibial plateau. Small effusion . ROM 0-120, limited by pain. Mild crepitus. (+) medial McMurray, medial knee pain with squat. No ligamentous laxity. Altman R et al. Arthritis Rheum. 1986 Aug;29(8):1039-49.

Clinical criteria for diagnosis of knee OA Altman R et al. Arthritis Rheum. 1986 Aug;29(8):1039-49.

Arthritis epidemiology  Most common type = osteoarthritis  Affects 23% of all adults in the United States ( > 54 million people)  More common in women (24%) than men (18%)  Affects • ½ of US adults with heart disease • ½ of US adults with diabetes • 1/3 of US adults with obesity  Osteoarthritis was the 2 nd most expensive health condition treated in US hospitals in 2013 https://www.cdc.gov/chronicdisease/resources/publications/aag/pdf/2016/aag-arthritis.pdf. Accessed November 18, 2017. 9 11/22/2017 McAlindon TE et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. 2014 Mar;22(3):363-88. Take-home points: knee OA, meniscus tears Does arthroscopic partial meniscectomy (APM) help middle aged patients with osteoarthritis +/- degenerative meniscus tear?  Arthroscopy not indicated for knee OA as no more effective than non operative  Degenerative meniscus tear is part of the natural history of care (Mosely JB et al, NEJM 2002; Kirkley A et al. NEJM 2008) osteoarthritis  ¾ studies show no significant difference between APM + PT versus PT alone  Treat as osteoarthritis initially with non surgical knee OA program (Gauffin H et al. Osteoarthritis Cartilage 2014; Herrlin SV et al. Knee Surg Sports Traumatol Arthrosc 2013; Katz JN et al. NEJM 2013; Yim JH et al. AJSM 2013.)  Imaging: Start with x-ray. Consider referral vs MRI if exam c/w • Limitation: difficult to interpret due to cross-over (30%) before assessment of meniscus tear and not improving with PT the primary outcome  Could consider arthroscopic meniscus surgery if weight loss, PT, • Factors associated with crossover from PT to APM: shorter duration of medications, injections not helping or if patient prefers surgical symptoms and higher initial pain score (Katz JN et al. JBJS 2016.) treatment.

McAlindon TE et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. 2014 Mar;22(3):363-88.

Indications for knee arthroscopy Which of the following would you recommend?  Acute (not degenerative) meniscus tear, no arthritis 60 y/o woman with 3 months knee pain due to medial compartment OA and degenerative tear of medical  Locked or locking knee: Bucket handle meniscus tear or loose meniscus. body  Ligament tear A. Refer for arthroscopic debridement of meniscus tear and • ACL – reconstruction lavage • MCL – often treated conservatively but sometimes B. Nonoperative knee OA program reconstructed C. Refer for total knee replacement • PCL – depends on whether or not other structures injured • LCL – reconstruction (rare injury) Case #2 How would you treat this patient? 50 y/o RHD woman with type 2 diabetes presents with 3 months of A.Provide R shoulder sling to use for comfort. severe R shoulder pain. No injury. Waking up at night due to pain. B.Provide shoulder steroid injection to reduce pain. Shoulder feels very stiff. She is having trouble reaching behind and raising arm above head. C.Obtain shoulder MRI. On exam she has no muscle atrophy and no point tenderness. There D.Refer to surgeon for arthroscopy. is decreased active and passive range of motion of the right shoulder. Her rotator cuff strength is 5/5 though difficult to perform due to limited range of motion and pain. R shoulder x-rays are normal.

Shoulder: diagnosis driven exam Adhesive capsulitis Active ROM Normal Decreased Rotator cuff disease Labral tear Passive ROM Biceps tendinitis AC joint OA Normal Decreased Adapted from: O'Kane and Frozen GH joint Xray Toresdahl. The evidenced- shoulder arthritis http://www.aurorahealthcare.org/he based shoulder evaluation. Cur Abnormal althgate/images/si55551230.jpg Normal Sports Med Rep. 2014. Shoulder active range of motion Shoulder active range of motion Internal rotation Internal rotation Abduction Abduction Forward flexion External rotation

Adhesive capsulitis is a clinical diagnosis Limited ER key finding  No need for MRI  X-rays helpful to r/o glenohumeral joint arthritis X-rays courtesy of Dr. Ben Ma 3 stages of adhesive capsulitis Treatment for adhesive capsulitis  Associated w/diabetes: A1c or fasting blood sugar  Pain control: NSAIDs or injected corticosteroids Freezing Frozen Thawing • Does not change disease course • Does help significantly with pain control 3-9 4-12 months 12-42 months Resolution  +/- physical therapy to help restore ROM months ↓ pain Gradual ↑ ROM Average ↑ pain Stable, time to  Capsular distention injections ↓ ROM decreased resolution: Manske and Prohaska, Curr Rev Musculoskeletal Med, 2008. ROM Pain at 1-3 years  Surgery (rarely) Griesser MJ et al. Adhesive capsulitis …a systematic review of rest, sleep intraarticular injections. J Bone Joint Surg Am. Sep 2011.

How would you treat this patient? Case #3  20 y/o collegiate cross country athlete 50 y/o RHD woman with 3 months severe R shoulder pain. Limited active and passive range of motion.  Presents to training room with right groin pain Normal x-rays.  Started a few weeks ago, getting worse gradually A. Provide R shoulder sling to use for comfort.  Still able to run but pain gets worse the more she runs, hard to lift her leg due to pain B. Provide shoulder steroid injection to reduce pain. C.Obtain shoulder MRI. D.Refer to surgeon for arthroscopy. Differential diagnosis groin pain in runner 5 questions for every runner with hip pain  Hip flexor strain 1. Training: increased mileage?  Femoral acetabular 2. Nutrition: Calories in versus calories out? History of impingement +/- hip eating d/o? Dietary restrictions? labral tear  Sports hernia 3. History of stress fractures?  Osteitis pubis 4. Family history of osteoporosis?  Femoral neck stress http://www.arthrohealth.com.au/wp- 5. Menstrual history? fracture content/themes/ypo- theme/images/CAM-and-Pincer.jpg  GI/gyn problems Falvey EC et al, BJSM. 2007.

Our patient What’s your leading diagnosis?  Increased mileage from 30 to 60 miles/week in last month A. Hip flexor strain without increased caloric intake B. Femoral acetabular impingement  No dietary restrictions or h/o eating d/o C. Sports hernia  (+) h/o tibial stress fracture in high school D. Osteitis pubis  No family history osteoporosis E. Femoral neck stress fracture  Menses regular until college but none since freshman F. GI / gyn problem year (18 months) High index of suspicion to prevent bad outcome Risk factors for bone stress injury in female athletes  Low bone mineral density (Bennell, 1996; Kelsey, 2007; Myburgh, 1990; Goolsby, 2008)  Delayed onset of menses and/or missing periods (Goolsby,2008; Bennell, 1996; Myburgh, 1990)  Lower dietary calcium (Kelsey, 2007)  Lower dietary fat (Bennell, 1996)  History of stress fracture (Goolsby, 2008; Kelsey, 2007)  Restrictive eating (Goolsby, 2008; Bennell, 1996)