Dr. Holly J. Benjamin distinguishes common sports-related acute traumatic injuries and provides tips on how to identify key findings on history and physical that aid in diagnosis. Dr. Benjamin also reviews the basic treatment recommendations and discusses indications for referral to a specialist for sports injuries.
HOLLY J. BENJAMIN: We're going to talk about sprain, strains, and sports injuries, and injury prevention today. If they give me 30 minutes I always try to squeeze as much in as possible, so I will move quickly. I just think that they always kind of-- my disclaimer is that I always get broad topics. And they always say well, cover all sports injuries and everything you need to know, how to treat, how to prevent. So that means that I have to talk fast and that comes easily to me. So thank you for being here. Epidemiology, it is something that everyone in this room as a parent, as a health care provider, as a family member, has to deal with. I mean, when you really look at the numbers of athletes as much as obesity is a problem, it's still staggering how many of our kids are active. We have 7 million in school programs, 20 million in organized sport programs, over 25 million in unstructured recreational sports. That might be your competitive club gymnast to just someone doing after school activities, which is a lot of our more underprivileged children. We do over 8 million pre-participation sports physicals a year for high school athletes alone. There are deaths related every year, which is very sad, head injury, cardiac, asthma, et cetera. But there are a lot of the musculoskeletal injuries that I'm here to talk about today that are often career ending. And it might seem shocking, but I'll bet all of you in this room know someone who's dealt with or quit a sport because of the type of injury that they had. And some of them seem like maybe they shouldn't have had to quit, or maybe something could have been done differently to make sure that they recovered. So we're going to talk a bit, as much as we can. Objectives today, understand what a sports medicine specialists is, which hopefully you know. But I still find myself explaining what I do. Sprains, strains, tendinitis will cover a bit of everything. We'll talk about risk factors for sports injuries and treatment recommendations and indications for referral. I don't want to spend too much time to bore you with what is a sports medicine doctor but I think of myself as someone who does nonsurgical orthopedics plus all the medical sports related problems. So I work with all primary care providers. I'm also a liaison to orthopedic surgeons. As you know, a lot of what you see, whether it's an overuse injury or traumatic injury like a straight up ankle sprain, doesn't necessarily need surgery but has a lot of information, a lot of questions into how to treat it, when is it safe to play. And that's I think where I come into play. I do a lot of communication with school's, athletic trainers, physical therapist, coaches, and parents. I sometimes said why I'm tired at the end of the day in pediatrics is because every patient is a minimum of a two-fer. So if you see 30, you've really seen 60 or more. All right, we're going to do this on a somewhat case base so we get our points across. So case one, acute ankle injury, a 16-year-old female basketball player landed on an opponents foot, inverted ankle, heard a pop, immediate swelling and bruising, unable to bear weight. Not all of these, as I'm sure you know, end up in the emergency room. They end up in urgent care centers and even in the office. We have a lot of folks that need to ice it up overnight and limp in. So we'll start with a very basic, what is a sprain? It's an injury to a ligament. A ligament connects two bones together. We see common areas are ankle sprains, knee sprains, and elbow sprains. Basic anatomy, again is remember, injuries to the outside. Medially there's the deltoid ligament here. Your subtalar joint is where we refocus ankle injuries on. And then your anterior talofibular ligament is the one that's most important to pay attention to in terms of sprains. In terms of key questions in the history, this is an important slide because these are the types of questions you should really ask for any sports related injury. The mechanism is very important, acute or overuse, and what exactly was moving. I know sometimes they say they don't know. But if they can tell you my arm was out, or my ankle turned in, or my knee buckled in, it's very helpful and very important to focus what you're evaluating. Where's the pain exactly, too? Sometimes it's everywhere. Is there swelling or bruising? And is there an inability to weight bear or any history of prior injury. One of the most common risk factors for a sport related injury is a history of a prior injury. All right, I have a few key take-home points. This is one of them, orthopedics is not rocket science. Although we try to sometimes pretend that it is. Find out what's tender and figure out what's there. So one of the most important parts of sports medicine in orthopedics is know your anatomy and listen to the patient. It makes you much more comfortable in diagnosis and treatment of injuries. In terms of ankle sprains, there is one ankle sprain per 10,000 persons per day. And that's about two million ankle sprains in the US per year. About 25% of them are related to running and jumping injuries. And about 30% to 50% occur in team sport play. So everyone in this room has dealt with an ankle sprain, right? The Ottawa Ankle Rules I'm often asked to review in terms of when do I get an x-ray. They do apply quite well in pediatrics when there's bone tenderness along the distal six centimeters of the tibia, the fibula, or the tip of the medial malleolus, or the tip of the lateral malleolus, and an inability to bear weight. And that could be an obviously office, urgent care, wherever. Whenever you see a significant amount of swelling or bruising something either tore or broke. And if you have bimalleolar swelling that's an indication of something going on, potentially intra-articularly. I don't want to spend too much time on a lot of data. I wanted to make this pretty clinical for you. But there are some very good studies that showed sensitivity of almost 100%, specificity about 40%. Nevertheless, there are some. If you apply the Ottawa Ankle Rules then you can save your patients some x-rays, which is helpful. All right, another take-home slide for you. The treatment of ankle sprains are the three P's, protect it, restore power, and then restore proprioception. OK, 50% of ankle sprains reoccur in the first six months, and that's usually because the third P isn't addressed. And we'll talk about three P's briefly. All right, grade 1 takes about 7 to 14 days, grade II, 2 to 6 weeks, grade 3, about 4 to 6 weeks. There's a variety of ways to immobilize the ankle. I would put to you that if they are limping with mild pain, if you can apply something like an air cast and they can walk without a limp with minimal to no pain, that's appropriate to send them out on. They don't necessarily need to be on crutches. If they're limping in their brace you either have to use crutches or you use something like some version of the CAM Walker. When do they come out of the CAM Walker if you put them in that? After about a week or two you can then go to a brace and from a brace to nothing. Or you look into these for our high schoolers. No, I'm just kidding. I'm sure someone paid a lot of money for those custom ortho C's. So criteria for return to play, I get asked about that a lot. Pain free, full range of motion, full strength, and then these are something you actually can long term incorporate in the office. It will make you a lot more comfortable for returning to play. A 10 second single leg balance test, a single leg pop, up to-- I start actually with toe raises and if they can do five toe raises actually I'll have them do five hops. And then if you can, you can try some running and cutting but usually I tell them test it out at home if they get through the single leg hops, the balancing, and everything else. I would put to you as another take-home point that's kind of buried in here, is proprioception, even if you use physical therapy, takes a long time to come back. Somewhere between six weeks and six months. So they need time to do home rehab programs or to see a physical therapist. So we brace up to six months after, I'd say, a minimum of six weeks after they returned to play In any kind of running or cutting sport. And up to six months should they stay in a protective brace while they are playing, OK. So prevention, since that was one of the themes of the talk. Return to Play is also prevention of injury. So we don't want everyone to have an injury to learn how to have strong knees and ankles. But a lot of the proprioceptive exercises that we do is the prevention of injury and I'll get to that again at the end. All right, case two, acute hip pain in an adolescent. A 16-year-old male, recreational athlete, running at full speed felt and heard a pop in his right groin resulting in 10 out of pain, or sometimes 12 out of 10 pain. They were seen in an emergency room, given crutches and ibuprofen but no diagnosis by the young intern who was there, who wasn't quite sure. In clinic their non-weight bearing. They have significant right inner thigh and groin pain. No ecchymosis, no signs of trauma, no defect, but tenderness in the inner thigh. So, I want you to think about what the diagnosis might be or at least the differential. OK, so common things being common, you would certainly think about adductor strains, or hip flexors strains, transient synovitis. Possibly though badness, SCFE, or apophyseal injury, and Perthes disease. Remember an apophysis is a growth plate where a muscle tendon unit attaches but is different than a epiphysis, where you get taller. That's the end of the long bone. So an apophysis is where you get Osgood-Schlatter's it's where you get Sever's disease, and things like that. All right, so hip pain I would put to you, imaging is very important. The likelihood in a teenager of having apophyseal injury is quite high. All right, so I would put to you that on this AP this is the right, this is the left, which one's injured? You have to shout it out. How many say left? How many say right? All right, very good. So there is the lesser troch. So if you look at the lesser trochanter here where the psoas attaches, a very common injury. If you see the difference there, there's a normal bump and it's kind of widened by about a centimeter or so there. So that's how you have to look at your radiographs. There's other growth plates there as well. So I'll show you this. So these are the ones. Hips are a little bit complicated but you do want to pay attention. That is actually a little bit of a less common injury. The two most common that I see are the anterior superior and anterior inferior iliac spine avulsing. Those are the hip pointers that people talk about in soccer. Where they're I feel like I've shot my hip. And they come in and they're limping, and three days later they want to play. And then the ischial tuberosity where the hamstring attaches as well. Those are the second most common that I see. So that's a nice little slide you can Google that, you can pull that up, and you can refer to it. You almost don't even need to know what muscle attaches but just where the growth plates are. All right, there are some complications of apophysitis. I had this young man that was actually diagnosed and treated as a hamstring strain and came back in and said, I feel better, I have less pain but, boy it feels like I've been sitting on a golf ball when I sit on my chair in school. And do you see what side is injured there? So he was indeed sitting on a golf ball. So he probably tore his hamstring attachment tendon and then bled into that and actually has myositis ossificans there. And he has to live with that. That is huge. That's the biggest one I've ever had in clinic. And he was better but basically had to, basically his advice was he could play sports. He did pretty well but we said permanently sit on soft surfaces. So the only time he had problems was on hard chairs. So he had to sit on a hoody or a cushion in school. Which is quite a problem in high school. They don't want to sit on pillows in school, so that's different. All right, that's my player with acute thigh pain and a limp. You will encounter this. Also, kids that come in with limp and feeling like their leg,or thigh, or knee is stiff and painful can have other injuries that are common but are surgical emergencies. So which side is injured here, the right or the left? I'm going to say, good, I hear you guys shouting out. Thank you. This is the old-- our old friend, the ice cream on the cone, the SCFE . Right, slipped capital femoral epiphysis. So, you've got to get a pelvis where you don't get hip films. AP frog leg pelvis, it's two views and you're done. The ice cream falls off the cone. And I'll go back so you can see what it looked like originally. See how this is kind of sclerotic and how off that is there? And then so there's your ice cream cone, there's ice cream falling off the cone. And there's your pin that Dr. Bilski would do for us, he'll be speaking later, and then off he goes and he gets better. So you don't want to miss that. So knee pain, thigh pain, or hip pain, any kind of stiffness in the hip you have to get an AP frog leg pelvis. All right? Strains and tendinitis, a strain is an injury to muscle. It's pretty straightforward but I do have people who sometimes confuse sprains and strains. And I'm just a little picky about that because that's what I do. A tendinitis is inflammation in the tendon and the tendon connects muscles to bone. There are a lot of overuse injuries but you can get acute strains as well. So we'll do this quick case. A 17-year-old football player feels pain on the right quad after sprinting 40 yards for a fourth quarter touchdown. After the game, in the locker room, he notices bruising to his right thigh. His team doctor evaluates him and suggests what? So, this is common especially in football to take helmets to the quad. Also see it in soccer and rugby a lot. And what does he have? Exactly, so he has a quad contusion strain. Treatment is gentle stretching, massage, icing, and a slow progression back to activities. They have a lot of stiffness and a lot of scar, and that's a problem. The difference of a contusion or hematoma, where they actually have very tight and a palpable mass. So, we actually treat them in hyperflexion for 24 hours. And we really do do that. We use a giant ace wrap and tape them up. It's basically a tourniquet effect and they have a much better recovery for that. So if you have a really severe one, I would treat it as, which I probably only do once or twice a year, more of a hematoma, severe contusion, and tape their leg up for 24 hours. Other than that it's probably more of a strain. When can they go back to sport? They can walk without a limp. They can jog without a limp. They can sprint without a limp. They can cut without a limp. They're good to go. And that can take anywhere from 7 to 10 days to 3 to 6 weeks. I would say typically these take a good three weeks minimum to resolve. So you see him back every week if you have to when they're anxious to go. If they're willing to take three or four weeks off and do some gentle rehab you don't have to see them as often. So, ACL injury, she tears her ACL. It's an intra-articular ligament. It is a life changing event if you tear your ACL. It's probably one of the most, sort of, mentally depressing and challenging injuries that athletes recover from with a lot of pain. And it's a long recovery, six months before they return to sport. There are about 250,000 per year. About 70% are sport related. And yes, it is more common in females. It's pivoting sports such as basketball, volleyball, and soccer are the most common. This is a sobering statistic, about 1 in 100 high school and 1 in 10 college females will suffer an ACL injury during their four year athletic career. It's up to eight times more common in females than males. What does it look like? You won't see it on an x-ray but on the MRI it connects the tibia and the femur. It tears usually mid-substance. So here's a normal ACL crossing the PCL. Here's where it's torn and you have two little stumps, and you're missing the ACL in-between. And that's what it looks like. This is something you refer. You either refer a suspected, like a big swollen and non-contact valgus knee injury to someone like myself to sort of work it up and figure it out or to the surgeons. Obviously I refer these onto the surgeons but I often prepare them with bracing and rehab. And the ball's kind of rolling and they sort of understand the severity of their injury. ACL prevention, I did want to bring that up because this is quite encouraging. In the last 10 years or so, when people started looking at this, was what is the first thing we do to rehabilitate sprains of ligaments and tears? We try to restore stability and proprioception in ankle sprains, MCL sprains, everything else. So, ACL prevention programs are looking at can we prevent an ACL injury? And they've shown some encouragement. You'll never prevent every injury but plyometrics, balance training, core strength, jump squat mechanics, about 2 to 3 times a week for a minimum of six weeks has shown some effectiveness in changing landing techniques for the ACL. So there are some good ACL prevention programs that are out there now. So you can offer that for your athlete whose worried about ACL or has a history of knee problems. And then in conclusion, many acute sprains and strains are not preventable. , However, injury prevention strategies include proper warm ups and cool downs, flexibility, core strength, and strength training in general, and sport specific biomechanics with good technique. We do encourage athletes to only do a single sport nine months out of the year at the most, and try to avoid early sports specialization. That does seem to decrease the injury risk in general. Although that probably has a better effect on preventing overuse injuries than acute injuries. Some of them they just aren't preventable. But it's exciting, all the things we can offer in sports medicine. So, thank you very much.