Sports Medicine 2015 Carlin Senter M.D. UCSF Internal Medicine and - PDF document

5/22/2015 Hot Topics in Sports Medicine 2015 Carlin Senter M.D. UCSF Internal Medicine and Orthopaedics UCSF Advances in Internal Medicine Hot Topics in Sports Medicine 2015 • Sports concussion – Diagnosis – Treatment • Knee pain due to osteoarthritis + meniscus tear – Exam – Treatment evidence • Rotator cuff tears – Physical examination evidence 1

5/22/2015 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.) 2

5/22/2015 Concussion numbers increasing Marin JR et al. Trends in visits for traumatic brain injury to emergency departments in the United States. JAMA. 2014 May 14;311(18):1917-9. 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 http://fuerzadesign.com/wp-content/uploads/2014/10/thumbnail-United-States.jpg 3

5/22/2015 Case #1 • 40 y/o woman presents to your office for ER follow-up two days after bike accident. • Slid out while crossing streetcar tracks on wet city streets. • No loss of consciousness. • Taken by ambulance to ER. • Had trauma work-up including head CT (-). • Has headache, fatigue, dizziness, light sensitivity. Trouble staying focused at work, sleeping more than usual. • Normal neck and neurologic exam. Concussion definition • Type of mild traumatic brain injury • Blow to head, neck, body  force to head • Rapid onset of neurologic impairment • Symptoms usually resolve in weeks, spontaneously, but in some cases can be prolonged. • May or may not include loss of consciousness. • CT and MRI studies are normal Adapted from 4th International Conference on Concussion in Sport (2012). Br J Sport Med. 4

5/22/2015 Concussion symptoms Physical Sleep Cognitive Emotional http://www.cdc.gov/ncipc/tbi/Facts_for_Physicians_booklet.pdf. Accessed Nov. 9, 2008. Clinic concussion evaluation • History of injury • PMHx ADHD, anxiety, depression, head injury • Clinical status: improving or worsening since time of injury? • Neck and neurological exam 5

5/22/2015 • Age > 60 • Decreased alertness after initially lucid • GCS < 14 initially or < 15 • High velocity injury (hit by two hours post injury car, fall from height) • Vomiting more than once • Comorbid illness • Seizure (cirrhosis, diabetes, • LOC immunosuppression) • Focal neuro deficit • Pregnancy • Suspected skull fx • Anticoagulants • Severe headache 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 policy statement. How severe is my concussion? • Concussion grading is retrospective – Historically concussions were graded on the sideline based on amnesia and LOC at time of injury. – American Academy of Neurology, 1997 – Cantu, 2001 – Studies have shown these factors not to be predictive of recovery. • Only when the athlete recovers can you tell how severe the concussion was http://thehoopla.wpengine.netdna-cdn.com/wp- content/uploads/2012/10/rage-meter-1.jpg 6

5/22/2015 Symptom resolution • Athletes become asymptomatic in 1-2 weeks ( Williams RM et al. Sports Med. 2015 Mar 28.) • Recovery in athletes may be faster than in others (Levin HS and Diaz-Arrastia RR. Lancet Neurol 2015; 14: 506-17.) • Pre-existing neuropsychiatric disorder associated with symptoms > 3 months (Levin HS and Diaz-Arrastia RR. Lancet Neurol 2015; 14: 506-17.) Case #1 • 40 y/o woman presents to your office for ER follow-up two days after bike accident. • Slid out while crossing streetcar tracks on wet city streets. • No loss of consciousness. • Taken by ambulance to ER. • Had trauma work-up including head CT (-). • Has headache, fatigue, dizziness, light sensitivity. Trouble staying focused at work, sleeping more than usual. • Normal neck and neurologic exam. 7

5/22/2015 How would you treat this patient? 1. Order urgent head CT to rule out subtle post traumatic bleed, return to clinic after CT. 2. Rest from work and biking, return to clinic 1 week. 3. Return to work but rest from biking, return to clinic in a month. 4. Return to work and biking. Concussion treatment • Cognitive rest • Physical rest • Medication – Tylenol – Ibuprofen after first 72 hours • No driving • No alcohol • Education 8

5/22/2015 Return to school/work progression Return to full day of school. Return to ½ day of school. 30 min schoolwork at 15 min a time until cognitive can do 1-2 No school. activity at a hours. 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 Physical rest • Evidence sparse on benefit of rest • Management largely guided by expert opinion • No same-day return to play • Once concussion symptoms have resolved gradually return to play 9

5/22/2015 Return to play progression 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 . Concussion statement 2012 10

5/22/2015 Case #2 • 55 y/o man with medial-sided pain and swelling of the R knee for 6 weeks. • No locking, no instability EFFUSION • Exam: effusion, tender medial joint line and 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 Area of tenderness http://www.ski-injury.com/kneeanat.gif, Accessed 10/04/05. Accessed 10/4/05 11

5/22/2015 Meniscus: McMurray Sensitivity medial 65%, Specificity medial 93% Magee, DJ. Orthopaedic Physical Assessment, 5 th ed. 2008. Meniscus: Thessaly Video used with permission from Anthony Luke, MD. 12

5/22/2015 Meniscus: squat Radiograph 3 views for knee pain – Weight bearing flexed PA (aka notch view) – Lateral of affected side – Sunrise or merchant view http://nurse-practitioners-and-physician- assistants.advanceweb.com/Features/Artic les/Knee-Osteoarthritis.aspx 13

5/22/2015 MRI - report • Menisci: complex degenerative tearing of the medial meniscus posterior horn and body. • Cruciate ligaments: intact • MCL/LCL: intact • Extensor mechanism: intact • Cartilage and bone: moderate-grade cartilage loss over the medial femoral condyle and medial tibial plateau Diagnosis? A. Medial meniscus tear B. ACL tear C. Moderate medial compartment osteoarthritis D. Patellar dislocation E. Septic arthritis F. Medial meniscus tear and moderate medial compartment osteoarthritis 14

5/22/2015 Initial treatment? A. Refer for arthroscopic debridement of meniscus tear and lavage B. Nonoperative knee OA program C. Refer for total knee arthroplasty • 188 patients followed x 2 years • Primary endpoint WOMAC score (knee pain + fxn) • Avg age 60, 2/3 female, BMI 31 • Excluded bucket handle meniscus and severe varus or valgus alignment 15

5/22/2015 Interventions • Control • Arthroscopic surgery – PT: 1 hour/week x 12 – Irrigation with saline weeks – 1 or more of the – Home ex program following: 2x/day • Debridement or excision of degenerative meniscus – Instruction on ADLS tears – Self management • Removal loose bodies, arthritis education chondral flaps, bone spurs reading + videotape – Medical and physical – Medications (APAP, therapy like controls NSAIDs, hyaluronic acid injections) Kirkley et al. A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee, NEJM, 2008. Results Kirkley et al. A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee, NEJM, 2008. 16

5/22/2015 Surgery vs PT for meniscal tear and OA • Multicenter RCT • 351 patients with meniscus tear + OA • Meniscus sxs (clicking, popping, catching, giving way, joint line pain, pain with twisting) • Avg. age 60 years • 50% men, 50% women • Primary outcome = change in WOMAC physical- function score between groups at 6 mo Katz JN et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013 May 2;368(18):1675-84. 17

5/22/2015 Interventions • Control (PT) • Arthroscopic partial – Usually 6 weeks meniscectomy (APM) – Trim damaged meniscus – 3-stage program back to stable rim • APAP, NSAIDs, – Remove loose cartilage intraarticular steroid and bone injections as needed • PT protocol • APAP, NSAIDs, intraarticular steroid injections as needed Katz JN et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013 May 2;368(18):1675-84. Results Katz JN et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013 May 2;368(18):1675-84. 18