Return to Play: Case Challenges Drew A. Lansdown, MD Assistant - PowerPoint PPT Presentation

12/14/2018 Financial Disclosures  No relevant financial disclosures related to this talk Return to Play: Case Challenges Drew A. Lansdown, MD Assistant Professor in Residence UCSF Department of Orthopedic Surgery Sports Medicine & Shoulder Surgery Outline The Team Physician and the Return-To-Play Decision: A Consensus Statement (2012 Update ) Goals Review the framework for return to PANEL, EXPERT. "The team physician and the return-to-play decision: a consensus statement—2012 update." (2012). 1. play decisions  These consensus statements are developed by the collaborative effort of 6 major professional associations: • Clarify factors that contribute to timing of return to play Discuss five cases and highlight important factors that contribute to timing of return to play 2. • Knee • Case-based presentations • Shoulder with active participation • Hip 1

12/14/2018 The Team Physician and the Return-To-Play The Team Physician and the Return-To-Play Decision: Decision: A Consensus Statement ( 2012 Update ) A Consensus Statement (2012 Update )  Key Points:  Definition : • It is essential that the team physician • Return-To-Play is the decision-making process of returning an ultimately be responsible for the RTP decision. injured or ill athlete to practice or competition. • Individual decisions regarding RTP may be  Goal : complex and will depend on the specific facts • The goal is to return an injured or ill athlete to practice or and circumstances presented to the team competition without putting the individual at undue risk for physician. injury or illness. Slide courtesy of Cindy Chang, MD Slide courtesy of Cindy Chang, MD Return to Play Decision Making The Team Physician and the Return-To-Play Decision: Sport Risk Modifiers Decision Modifiers Medical Factors A Consensus Statement (2012 Update ) • Type of sport • Timing & season • Patient demographics  The status of anatomical and  Restoration of sport-specific skills • Pressure from • Symptoms • Position functional healing athlete • Limb dominance • Medical history  Psychosocial readiness • External pressure  The status of recovery from acute • Physical exam • Competitive level  Ability to perform safely with illness and associated sequelae • Masking the • Ability to protect equipment modification, bracing, • Lab/Imaging Tests injury (padding)  The status of chronic injury or illness and orthoses • Functional Tests • Conflict of  That the athlete pose no undue risk  Compliance with applicable federal, • Psychological State interest to the safety of other participants state, local, school, and governing • Potential Seriousness • Fear of litigation body regulations Final Return to Play Decision Slide courtesy of Cindy Chang, MD 2

12/14/2018 Case #1: Knee Sprain  20 year old woman presents with new-onset right knee pain after collision with another player while playing soccer:  Seen 3 days after injury Return to Play Cases  Pain is medial at the right knee  No knee effusion  Pain with valgus stress and opening of 3-4 mm  Negative Lachman  Negative pivot Image: fittoplay.org ARS Question Medial Collateral Ligament Most likely diagnosis for this patient? • Protect against valgus stress at the knee Function • Comprised of deep and superficial components 86% A. ACL tear • Best isolated with knee flexed to 30 degrees B. MCL sprain • Check at 0 degrees with laxity in extension Exam C. Lateral meniscus injury suggesting associated ligament injury • Evaluating for pain and opening D. Patellar cartilage injury • Grade 1: Stretch • <5 mm opening to valgus stress at 30 degrees 11% • Grade 2: Partial Tear 3% 0% • 5-9 mm opening to valgus stress at 30 degrees Grading • Still with an end point to valgus stress ACL tear MCL sprain Lateral meniscus injury Patellar cartilage injury • Grade 3: Complete Tear • >1 cm opening to valgus stress at 30 degrees 3

12/14/2018 MCL Injuries When Will I Be Able To Play?  Mid-substance healing is A. Tomorrow EXAM quicker than injury at insertion • Pain is medial at the right knee B. 2 weeks  MCL more common due to • No knee effusion C. 3 months contact injury • Pain with valgus stress and D. 6 months opening of 3-4 mm  More common in last 15 E. 1 year • Negative Lachman minutes of a half 73% • Negative pivot • Likely inability to protect due to fatigue DIAGNOSIS Grade 1 MCL sprain 22% 5% 0% 0% w s s s r k h h a o e t t e r e n n y r w o o o 1 m m m 2 o 3 6 T Illustration from Laprade, et al. JBJS, 2007. Role of Bracing  Hinged knee brace with side supports  Longitudinal cohort of isolated MCL sprains at US Military  Brace may allow for early motion Academy from 2005-2009  Recommend bracing a Grade 2  128 cadets with MCL injuries: or 3 injury rate of 7.3 per 1,000 person-  Not much benefit for Grade 1 years injury  Median return to play timing: • Grade 1: 13.5 days • Higher grade: 29 days 4

12/14/2018 When Should I Get More Imaging? Case #2: Another Knee Injury  21 yo male, collegiate wrestler, presents with right knee injury  Knee effusion • Wrestling a heavyweight teammate  Restricted range of motion and right knee buckled  Opening to valgus stress in • Felt a pop, immediate pain, and swelling soon after full extension MCL  Exam: • Suspect another ligament is • Range of motion: 10-90 degrees injured • Large effusion  Persistent symptoms that are • No specific tenderness not responding to • 2B Lachman conservative treatment • Stable to varus and valgus stress at 0 and 30 degrees ARS Question: What Is The Most Likely Diagnosis? What Should We Do Next? Most likely diagnosis is: 93% A. ACL tear A. Brace and protected weight B. MCL sprain bearing, follow up in 6 weeks History: • Felt a pop C. Lateral meniscus injury B. Progressive mobilization and • Immediate swelling D. Patellar cartilage injury return to wrestling in 1-2 days Exam: C. Ice, NSAIDs, and re-evaluate • Range of motion: 10-90 2% 2% 2% next week degrees • Large effusion r n D. MRI of the knee a y y e a i r r t r u u History: p n j j L s n C i i • No specific tenderness A L s e C u g M c a s l n i i r t • Pop and immediate swelling e a m c • 2B Lachman l r a a r l l 83% e e t t a a Exam: L P • Stable to varus and valgus • Range of motion: 10-90 degrees stress at 0 and 30 degrees • Large effusion Diagnosis: Acute ACL injury • 2B Lachman 17% • Stable to varus and valgus stress at 0 0% 0% and 30 degrees e . . . . . . . . e i . n u n e o l k w i a t v e d a e h z - e i e t t i l r f c b o e o d t m n R I o a r M p e , v s d i D n s I s A a e S e r N g c o a r e , r P B c I 5

12/14/2018 Non-Operative Treatment of ACL Tears  May require crutches/brace initially for support  Range of motion, quad strengthening  121 active young adults with acute ACL injuries  Core/hamstring strengthening exercises  Randomized to: • Initial rehabilitation and early surgical ACL  Balance/proprioception reconstruction • Rehabilitation and possible delayed ACL  Functional screening prior to return to sport reconstruction if needed  60 patients treated with early reconstruction  Anticipate at least 10-12 weeks before return to activity  59 treated with rehabilitation  40% chance of late reconstruction • 36 successfully managed with rehab alone • 23 underwent delayed ACL reconstruction • Avoided surgery in 61% Risks of Non-Operative Treatment  Possibility of late ACL reconstruction  Meta-analysis including 7,556 participants  Meniscal/cartilage injuries  Other ligamentous injuries to the knee 81% 65% 55% Return to Sport Return to Pre- Injury Level Return to Competitive Level 6

12/14/2018 Progression of Activity after ACL Reconstruction Risk of Re-Injury  Brace for 6 weeks  Re-injury with return to play  Return to sports based on functional testing • Rate varies based on timing of return • Running at ~4 months • 51% decrease per month of extended rehabilitation • Cutting/pivoting sports as early as 6  Desire to return to play/not miss a season months after surgery  Functional evaluation prior to return • For most, 9-12 months after surgery  Functional testing:  Role of bracing in return to play • Single leg squat control before starting to run • Hop tests when closer to returning to sport When Can I Wrestle Again? Case #3: Meniscus Tears  16 year old girl with 4 months of right  Rising senior knee pain:  One year of eligibility left for collegiate • Hyperextended knee going after wrestling contested ball in soccer game  7 ½ months until qualifying tournament • Felt pain, but able to keep playing for next year • No pop  Treatment plan: • Knee swelling that night • Restore range of motion quickly (2-3 • Continued to play weeks) • Pain and swelling after playing and after • ACL reconstruction with BTB even walking autograft  Exam: + McMurray’s laterally, tender at • Close communication with training lateral joint line staff  MRI: radial tear of lateral meniscus 7