1
Sports Medicine for Primary Care
Physicians

• Dr. Donald W. Kucharzyk
• The Orthopaedic, Pediatric Spine
• Institute
• Crown Point, Indiana

2
Sports Medicine for Primary Care Physicians

• Pediatric Athletic Sports Related Injuries
• Female Athletic Sports Injuries
• Preventing Sports Injuries in Female Athletes
• COX-2 Specific Inhibitors Emerging Role in
  Sports Medicine

3
Sports Medicine for Primary Care Physicians

• Musculoskeletal Overuse
• Syndromes

4
Sports Medicine for Primary Care Physicians

• Increased Musculoskeletal stress is common in our
  young athletes recently
• Reflects the escalating intensity of training and
  competition at younger ages
• Athletes go from one sport to the next with
  prolonged seasons and little rest
• Excessive use produces unresolved stresses on
  normal tissues that has yet to adapt and leads to
  failure and overuse

5
Sports Medicine for Primary Care Physicians

• Overuse injuries occur at two particular times
  during training
• First occurs when underused athletes who are
  partially conditioned are placed in demand
  situations pre-season football and cross country
• Second occurs in the extremely fit athlete who
  are participating in multiple sports resulting in
  depletion of tissue reserves

6
Sports Medicine for Primary Care Physicians

• History is the best primary aid to the diagnosis
  of overuse injuries
• Mechanical Pain that is produced by activity and
  relieved by rest is the hallmark anatomic factor
• Environmental factors such as playing surfaces
  and equipment play a role
• The most significant factor though is the
  training programs sudden increases or changes

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Sports Medicine for Primary Care Physicians

• Overuse treatment protocol involves five phases
• Identify risk factors
• Modify offending factors
• Institute pain control
• Undertake progressive rehabilitation
• Continue maintenance to prevent re-injury

8
Sports Medicine for Primary Care Physicians

• Stress Fractures
• Stanitski proposed the etiology to be the result
  of highly concentrated eccentric and concentric
  muscle forces acting across specific bones and
  compounded by specific sports specific demands
  predispose the bone to failure
• Loss of normal time frame for bone repair
  submaximal trauma produces the fracture

9
Sports Medicine for Primary Care Physicians

• Muscle fatigue also plays a role in stress
  fractures
• With fatigue of the muscle envelope, greater
  stress is absorbed by the underlying bone and
  predispose to stress fractures
• Increased muscle force--change in remodeling
  rate--resorption and rarefaction--microfractures--
  stress fx

10
Sports Medicine for Primary Care Physicians

• Standard radiographs are not helpful because
  early phase stress fractures are radiographically
  silent
• Bone Scans are extremely helpful but may not be
  positive till 12-15 days post injury
• Locations involve primarily the tibia but also
  has been seen in the upper extremity such as the
  humerus and radius and proximal femoral neck

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Sports Medicine for Primary Care Physicians

• Treatment regime involves immobilization via a
  pneumatic leg brace this helps distribute the
  stress across the soft tissue envelope that will
  diminish stress across the fracture and allow
  healing to progress
• Post healing rehabilitation is critical as well
  as evaluating the mechanics of the injury and
  training/conditioning and gait too.

12
Sports Medicine for Primary Care Physicians

• Stress Injuries of the Growth Plate
• Must be aware that chronic stress injuries can
  cause physeal damage
• Runners show this manifestation in the distal
  femur and proximal tibia--attention to history,
  clinical exam, and xray evaluation
  important..confused with neoplasm
• Areas Affected Include Proximal Humerus
  commonly seen in Pitchers

13
Sports Medicine for Primary Care Physicians

• Gymnasts have the most common physeal stress
  fracture seen affecting the distal radius--will
  retard growth and produce an overgrowth of the
  ulna and wrist pain
• Treatment is rest, immobilization, avoidance,
  rehabilitation, and conditioning
• Treatment course involves at least 3 months of
  avoidance and then rehabilitation

14
Sports Medicine for Primary Care Physicians

• Little League Shoulder
• Microtrauma and overuse to the upper extremity
  localized to the proximal humerus
• Mechanics of pitching produces stress across the
  physis during the cocking phase, acceleration
  phase, and the follow-through-greatest stress on
  physis at this time
• Radiographs reveal widening of the proximal
  humeral physis

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Sports Medicine for Primary Care Physicians

• Treatment is rest from throwing for the remainder
  of the season plus a vigorous preseason
  conditioning program the following year
• Recommendation to the family involves the
  evaluation of the athletes throwing mechanics, in
  immature pitchers development of skill and
  control, then with maturity develop speed and
  velocity

16
Sports Medicine for Primary Care Physicians

• Little League Elbow
• Medial elbow pain in tennis players, javelin
  throwers, and football quarterbacks
• Complex grouping of injuries involving medial
  epicondylar fractures, medial apophysitis, and
  ligamentous injuries
• Pain is the most common complaint
• Duration of pain aides in the diagnosis

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Sports Medicine for Primary Care Physicians

• Short duration must consider avulsion fx
• Longer duration consider ligamentous injury or
  medial apophysitis
• Radiographs lead to the diagnosis in fractures,
  but normal variants must be understood especially
  medially
• MRI gaining importance in use in these injuries
  as it gives great details of all the structures

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Sports Medicine for Primary Care Physicians

• Treatment is diagnosis specific
• Medial Apophysitis-medial pain,diminished
  throwing effectiveness, and decreased distance
  rest (4-6 weeks), NSAID, ice, gradual return to
  conditioning and resume throwing at about 8 weeks
• Medial Epicondylar Fractures-nondisplaced
  treat with cast and rehab displaced 3mm or more
  treat with ORIF

19
Sports Medicine for Primary Care Physicians

• Medial Ligament Rupture-sudden onset of severe
  pain with instability treatment is via direct
  surgical repair and if tenuous then supplement
  with a palmaris longus graft

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Sports Medicine for Primary Care Physicians

• Panners Disease
• Osteochondrosis of the capitellum (necrosis or
  fragmentation followed by recalcification)
• Seen in children aged 7 to 12 years of age
• Dull,ache that is aggravated by activity
  especially throwing
• Pain always LATERAL
• Radiographs reveal fragmentation and
  irregularities of the capitellum

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Sports Medicine for Primary Care Physicians

• Treatment involves initially rest, avoidance of
  throwing, and splinting until pain and tenderness
  subsides
• Rehabilitation and reconditioning of the upper
  extremity post recover important
• Late deformity and collapse of the articular
  surface of the capitellun uncommon

22
Sports Medicine for Primary Care Physicians

• Iliac Apophysitis
• Iliac crest tenderness on palpation and muscular
  contraction seen primarily in adolescent long
  distant runners
• No local trauma but history of extensive
  intensive training programs
• Radiographs are normal
• Treatment is rest (4-6weeks), ice, NSAID,
  progressive return to sports

23
Sports Medicine for Primary Care Physicians

• Osgood-Schlatter Disease
• Classic presentation is seen in preteen or early
  teenage children with activity related
  discomfort, swelling, and tibial tubercle
  tenderness
• Bilateral occurrence in 20 to 30
• Etiology is submaximal repetitive tensile
  stresses acting on an immature patellar
  tendon-tibial tubercle junction

24
Sports Medicine for Primary Care Physicians

• Muscle imbalance is commonly seen with weakness
  in the quadriceps sometimes significant
• Treatment is avoidance of activity,
  rehabilitation of the weak quadriceps, hamstrings
  and flexibility training, and progressive return
  to sports
• Family must understand that it can take from 12
  to 18 months for all symptoms to subside

25
Sports Medicine for Primary Care Physicians

• Sinding-Larsen-Johansson Disease
• Anterior knee pain at inferior pole of the
  patella
• Seen commonly in 10 to 12 year olds
• Tenderness seen at the inferior end of the
  patella at the tendon-bone junction
• Must evaluate for sleeve fracture or patellar
  stress fractures if history of sudden onset

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Sports Medicine for Primary Care Physicians

• Treatment involves rest, ice, NSAID, and
  occassionally a knee sleeve for protection
• Rehabilitation program to promote flexibility,
  quadriceps and hamstring conditioning, and return
  to normal activities to tolerance

27
Sports Medicine for Primary Care Physicians

• Slipped Capital Femoral Epiphysis
• Most common hip disorder seen in adolescent
• Slippage of the proximal femoral epiphysis
• Seen in two body types tall, slender, rapidly
  growing or the short, obese child
• Bilateral in 50
• Common cause of anterior thigh or knee pain,
  athletes with knee pain should have the hip
  evaluated too

28
Sports Medicine for Primary Care Physicians

• Gait abnormality is the common initial presenting
  complaint with a limp seen
• External rotational deformity of the hip seen
  (obligatory external rotation)
• Pain can be seen under 3 weeks (acute) over 3
  weeks (chronic)
• Treatment is immediate percutaneous hip pinning

29
Sports Medicine for Primary Care Physicians

• Patello-Femoral Malalignment
• Common source of sports disability especially in
  jumpers and those sports requiring rapid changes
  in direction
• May be related to congenital, acquired such as in
  Downs or Ehlers-Danlos syndrome, or acquired due
  to trauma
• Can be seen in association with flexible flat
  footedness due to valgus thrust on the patella

30
Sports Medicine for Primary Care Physicians

• Common symptoms include vague, localized anterior
  knee discomfort
• Seen following prolonged sitting, stair accent
  and descent, and with increase levels of activity
• Clinically evaluate for mechanical alignment of
  the lower extremity, movement of the patella on
  flexion/extension, quadriceps function and size,
  hamstring function and overall flexibility

31
Sports Medicine for Primary Care Physicians

• Gait analysis for femoral anteversion or tibial
  torsion should be studied as well as the
  evaluation for flexible flat footedness
• Radiographic evaluation involves plain x-rays
  with Merchant view to see patellar alignment and
  position
• Treatment is symptomatic via rest, NSAID,
  physical therapy and sometimes bracing

32
Sports Medicine for Primary Care Physicians

• Rehabilitation is the key to preventing the
  reoccurrence of the condition
• Failure to respond with prolonged symptoms and
  persistent subluxation with pain may benefit from
  arthroscopic lateral retinacular release
• Long term sequlae may predispose the patient to
  the development of chondromalacia patella

33
Sports Medicine for Primary Care Physicians

• Osteochondritis Dissecans
• Lesion of bone and articular cartilage of
  uncertain etiology that results in delamination
  of subchondral bone with articular cartilage
  mantle involvement
• Peak appearance is seen in early adolescence with
  male predominance 31
• Seen in the knee but can also be seen in the
  ankle involving the talus and the patella

34
Sports Medicine for Primary Care Physicians

• Clinically presents with vague knee pain that is
  aggravated with sports, intermittent swelling
  seen, and at times a feeling of the knee locking
• Physical exam is nonspecific
• Radiographic evaluation includes x-ray's and if
  indicated an MRI
• Most importantly, must differentiate acute
  lesions from silent chronic lesions

35
Sports Medicine for Primary Care Physicians

• Treatment geared to eliminate the pathologic
  process and clinical condition via repair or
  resection of the lesion
• Chronic lesions loose bodies require removal
  arthroscopically and debridement of the bed
• Acute lesions require drilling of the bed and
  fixation arthroscopically to allow the lesion to
  heal

36
Sports Medicine for Primary Care Physicians

• Patellar osteochondritis is treated similar to
  that of femoral osteochondritis with arthroscopic
  evaluation and debridement and curettage of the
  lesion
• Lesion commonly seen in the lower third of the
  patella and is due to increased patello-femoral
  contact force during flexion in the presence of
  weak quadriceps and minor trauma

37
Sports Medicine for Primary Care Physicians

• Ligamentous Injuries
• Common in Athletes
• Loaded in tension to provide both static and
  dynamic support to the knee
• Knee has motion that occurs in three planes and
  requires this static and dynamic support
• Kinematics of the Knee shows that any one plane
  motion is always coupled with a second plane
  motion

38
Sports Medicine for Primary Care Physicians

• Must Understand the Healing Process of the
  different ligaments
• Collateral Ligaments have a rich blood supply
  from the surrounding tissue and heals well with
  conservative care
• Cruciate Ligaments have a sparse blood supply
  from surrounding tissue and bone attachment and
  do not heal well with conservative care

39
Sports Medicine for Primary Care Physicians

• Healing process begins with fibrin clot formation
  and then a local inflammatory response
• First week post local vascular and fibroblast
  proliferation
• Second week post fibroblasts become organized
  into a parallel network
• Third week post tensile strength increases

40
Sports Medicine for Primary Care Physicians

• Eighth week post normal appearing ligament is
  now present
• Early range of motion critical to increasing the
  strength and energy-absorbing capacity of the
  ligament
• Immobilization not favorable to healing and
  recover of the ligament

41
Sports Medicine for Primary Care Physicians

• Medial Collateral Ligament
• Primary restraint to valgus stress
• Commonly injured by a direct blow to the lateral
  side of the knee with the foot planted
• Clinical signs reveal tenderness at the medial
  epicondyle with localized swelling
• Pain on valgus stressing or laxity seen define
  the grade of injury

42
Sports Medicine for Primary Care Physicians

• Lateral Collateral Ligament
• Primary restraint to varus stress
• Commonly injured with direct blow to the medial
  side of the knee with the foot planted
• Clinical signs reveal tenderness over the lateral
  epicondyle with localized swelling
• Pain with varus stressing or laxity reveal the
  grade of injury

43
Sports Medicine for Primary Care Physicians

• Treatment of Collateral Injuries
• Grade I do not require bracing, Grade II and III
  require the use of a hinged ROM brace with motion
  limited at 10 to 75 deg. initially for the first
  three weeks
• Early therapy important and include patellar
  mobilization, isometric quadriceps and hamstring
  exercises with modalities of whirlpool, E-Stim.,
  and biofeedback

44
Sports Medicine for Primary Care Physicians

• Bracing discontinued for Grade II and III at four
  weeks and achieving full ROM is now the goal
• Once FULL ROM achieved then begin flexibility and
  strengthening program
• Program includes leg presses, mini-squats,
  resisted knee flexion, proprioceptive training
  and swimming leading to a sports- specific
  training program (return 2-8 wks)

45
Sports Medicine for Primary Care Physicians

• Anterior Cruciate Ligament
• Primary stabilizer to anterior displacement of
  the tibia on the femur
• Secondary role is in the control of rotation of
  the tibia on the femur and to aide in
  varus-valgus stability
• Common mechanism of injury is a twisting force to
  the knee accompanied by a varus, valgus, or
  hyperextension stress to the limb

46
Sports Medicine for Primary Care Physicians

• Clinically feels a pop in the knee
• Inability to continue to play with a difficult
  time putting weight on the limb
• Gradual onset of swelling over the next 24 hours
  (acute swelling think chondral fx.)
• Examination reveals a positive Lachman Test,
  positive Drawer sign, and Pivot-Shift sign
• Evaluate for other associated injuries

47
Sports Medicine for Primary Care Physicians

• Non-Operative Treatment
• Goal is functional stability
• Initially reduce pain and swelling with NSAIDS,
  PT, and crutches
• Immobilization not necessary
• Intermediate rehabilitation involves ROM, gait
  training, strengthening and proprioceptive
  training

48
Sports Medicine for Primary Care Physicians

• Once effusion down and ROM full, then begin
  swimming and bicycling followed by light jogging
• Late phase rehab includes functional training
• Return to sports 6 to 12 weeks
• Must attain 90 of the unaffected extremity
  strength before return to sports
• Bracing is not absolutely indicated (no evidence
  to support functional bracing)

49
Sports Medicine for Primary Care Physicians

• Anterior Cruciate Ligament
• Isolated disruptions are unusual in children
• Two types exist nontraumatic cruciate
  insufficiency and post traumatic cruciate
  insufficiency
• Nontraumatic Insufficiency have inherent joint
  laxity of the knee as well as other joints

50
Sports Medicine for Primary Care Physicians

• Positive anterior drawer sign but firm end point
  on Lachman test
• Findings are seen bilaterally
• Athletic participation should be limited
• Most will be asymptomatic with activity
  modification

51
Sports Medicine for Primary Care Physicians

• Traumatic Anterior Cruciate Insufficiency
• Can be seen in traumatic avulsions of the tibial
  eminence with positive radiographic findings
• Laxity is commonly seen with acute hemarthrosis
  and often associated with damage to the
  supporting ligaments and meniscus
• Treatment involves arthroscopic evaluation,
  reduction and internal fixation via bioabsorbable
  pins and casting

52
Sports Medicine for Primary Care Physicians

• Isolated Anterior Cruciate Ligament
• Divided into two groups those without functional
  instability and those with
• In those without limitations, conditioning and
  participation in sports without limitations can
  occur
• In those with limitations, thorough evaluation
  for other associated injuries must be undertaken
  MRI and Plain X-ray's

53
Sports Medicine for Primary Care Physicians

• Arthroscopic evaluation is carried out to
  evaluate the site and magnitude of the ACL tear
  and if any peripheral meniscal lesions are seen
  then repair carried out
• If avulsion from tibia or femur found then
  primary repair performed regardless of age
• If midsubstance tear with growth left,
  conservative treatment undertaken
• If no growth left evaluate sport situation

54
Sports Medicine for Primary Care Physicians

• Conservative treatment involves rest for 7-10
  days, progressive range of motion over next four
  weeks, quadriceps and hamstring conditioning
  exercises are begun
• Maintenance program instituted and a functional
  brace provided and wait until skeletally mature
  for reconstruction
• Skeletally mature and achieved goals of
  rehabilitation then return to sports without brace

55
Sports Medicine for Primary Care Physicians

• If ACL torn and functionally impaired with little
  growth left, then reconstruction performed
• Treatment geared to prevent further damage to the
  joint, meniscus, and articular cartilage
• Surgical techniques multiple and center around
  the use of the patellar tendon or
  semitendinosus/tendon graft transfer

56
Sports Medicine for Primary Care Physicians

• Guidelines for ACL Treatment
• Physiologically young person who remains active
  in sports and will not modify activities,
  surgical intervention if not skeletally immature
  if immature wait till maturity
• Surgery for those with associated risk factors
  for instability such as collateral ligament tears
  or meniscal tears
• Older athlete modify activity and conservative

57
Sports Medicine for Primary Care Physicians

• Female Sports Related Injuries
• Shoulder Instability
• Preventing Knee Injuries
• Patellofemoral Problems in Women
• Preventing Exercise-Related injuries

58
Sports Medicine for Primary Care Physicians

• Shoulder Instability
• Shoulder instability in the female athlete is a
  difficult problem to identify
• Identifying the type of instability is the
  biggest challenge faced
• Traumatic versus ligamentous laxity
• Ligamentous Laxity is the more common and seen
  with pain as the predominant complaint

59
Sports Medicine for Primary Care Physicians

• Sex differences put the female athlete at risk
  for shoulder injuries
• Women have shorter upper limbs relative to total
  body length and thus upper girdle musculature and
  limbs work harder in certain sports ie. Swimming
• Shorter limb and lever arm tends to promote
  capsular laxity compared to men and increases
  stresses on the shoulder girdle increases
  instability and capsular laxity

60
Sports Medicine for Primary Care Physicians

• Identify Instability by the mechanism of injury,
  by the degree of instability, direction of
  dislocation or subluxation, and type of onset
• Types seen Acute Dislocation,Recurrent
  Instability,Atraumatic Instability, and
  Repetitive Microtrauma
• Most Common Type seen in the female athlete is
  the nontraumatic microinstability or subluxation
  injury due to capsular laxity

61
Sports Medicine for Primary Care Physicians

• Acute Dislocation due to trauma with anterior
  dislocation seen in 95 of the cases
• Dislocations can cause anterior detachment of the
  labrum or capsule from the glenoid Bankart
  Lesion
• Lesion associated with increased ligament laxity,
  stretching of the capsule, and loss of
  labrum-mediated stabilizing support

62
Sports Medicine for Primary Care Physicians

• Recurrent Instability due to repeated
  glenohumeral dislocations or subluxation that
  stretch the capsule and ligaments, leading to
  increased laxity and instability
• Resultant Natural History of chronic dislocations
  with unhealed Bankart lesions
• Secondary Etiology Congenital Inherent Laxity of
  the shoulder joint (Genetic)

63
Sports Medicine for Primary Care Physicians

• Atraumatic Instability typically a
  micro-instability or a subluxation disability
• Referred to at times as multi-directional
  instability due to the movement of the head
  abnormally in multiple planes
• Generalized laxity of the capsule and ligaments
  seen with associated fraying of the glenoid labrum

64
Sports Medicine for Primary Care Physicians

• Repetitive Microtrauma commonly seen in athletes
  that participate in excessive overhead motions
• Damages the anterior stabilizing structures of
  the shoulder joint
• If associated with congenital joint laxity, then
  pain due to impingement of the rotator cuff is
  also seen

65
Sports Medicine for Primary Care Physicians

• Clinical History will give clue to cause and the
  possible etiology
• Physical examination evaluates passive and active
  motion, palpable pain location, instability signs
  such as inferior instability test,
  anterior-posterior instability test, apprehension
  test, anterior relocation test(Jobe),and axial
  load test
• Imaging X-ray's and MRI

66
Sports Medicine for Primary Care Physicians

• Treatment
• Acute Dislocation Reduction of the dislocation
  followed by immobilization for three to four
  weeks and the rehabilitation
• Emphasis placed on early and safe ROM for the
  first six weeks followed by strengthening of the
  dynamic stabilizers of the shoulder and capsule
• Return to sports 12-20 weeks

67
Sports Medicine for Primary Care Physicians

• Atraumatic Instability cornerstone is
  rehabilitation with specific strengthening of the
  muscles that protect the shoulder joint from
  instability and discomfort
• Sports specific rehabilitation is the KEY
• Importantly, restrict those motions that elicit
  pain and promote those that do not
• Failure requires workup and possible shoulder
  stabilization procedure (arthroscopic)

68
Sports Medicine for Primary Care Physicians

• Prevention
• Essential Elements to Prevention strengthening
  the muscles of the shoulder girdle and structured
  pre-sport and sport specific strength training
  activities
• Avoid weight training with the load above the
  shoulder as well as avoiding weight machines due
  to design, and evaluate technique of the athlete

69
Sports Medicine for Primary Care Physicians

• Preventing Knee Injuries in Female Athletes
• 20,000 injuries occur in female athletes
• Due to marked imbalance in hamstring and
  quadriceps muscle strength
• Highest incidence of injury in the untrained
  athlete
• 3.6 times more likely to have an injury than the
  trained athlete

70
Sports Medicine for Primary Care Physicians

• Strength training programs that include
  plyometrics, stretching, and strength training
  have decreased the imbalance and reduces injuries
• These program should emphasize muscle balancing,
  muscle re-education, and sport specific training
  programs and in the long run turns out to be a
  simple and cost-effective means to reduce injury

71
Sports Medicine for Primary Care Physicians

• Patellofemoral Problems in Female Athletes
• Anterior knee pain in our female athletes is a
  frustrating problem
• Atraumatic knee pain is commonly due to soft
  tissue overload and overuse
• Occurs when the demand overwhelms the bodys
  ability to maintain homeostasis
• Factors influence activity changes, training
  errors, flexibility deficits, and weakness

72
Sports Medicine for Primary Care Physicians

• Clinical History will determine if the patients
  problems are related to anterior pain only or
  instability
• Anterior pain is commonly worse with prolonged
  flexion of the knee and sitting in one position,
  activity related pain always seen, and symptoms
  aggravated by walking up or down stairs

73
Sports Medicine for Primary Care Physicians

• Patellofemoral instability is identified by the
  feeling of the knee giving way and the knee cap
  feeling like its out of place
• Associated with activity but moreso full weight
  bearing activities that involve twisting motions
• Low Energy injuries or the so called trivial
  injuries should alert one to the diagnosis of
  Patello-femoral instability

74
Sports Medicine for Primary Care Physicians

• Clinical examination involves careful evaluation
  of the knee mechanics, muscle strength and size,
  palpation of the knee cap, and tracking of the
  patella
• Evaluate alignment of the leg, shape, and size as
  well as flexibility of the limb
• Evaluate patellofemoral alignment
• Evaluate pain generator coming from the patella

75
Sports Medicine for Primary Care Physicians

• Imaging involves x-rays including AP,Lateral and
  Obliques with Merchant view to see tracking of
  the patella
• Treatment is usually non-operative and begins
  with activity modification
• Dye Envelope of Function is a concept to
  achieve a balance between activity/work that a
  patient can do without leaving a state of
  homeostasis

76
Sports Medicine for Primary Care Physicians

• Key Goal to treatment is to achieve a pain free
  envelope of function through avoidance of
  provocative activities until conditioning
  dictates a return
• Strengthening should not stress the envelope and
  should be initially geared at the submaximal
  level until rehab sufficient
• Specific exercises should be performed to enhance
  the deficient muscle groups

77
Sports Medicine for Primary Care Physicians

• Quadriceps and Hamstring Balancing exercises and
  conditioning critical as well as VMO exercises
• Stretching program is important as flexibility is
  key to rehab but moreso to prevention and
  re-education of the appropriate muscle groups
• Taping beneficial during rehab but not long
  termsecondary deterioration of muscles

78
Sports Medicine for Primary Care Physicians

• Surgical correction can be effective but after
  all conservative measures exhausted
• Arthroscopic Lateral Releases work BEST initially
  but without proper re-education, will deteriorate
  after two-three years
• Proximal or Distal Realignment procedures are
  then required with proximal muscle re-alignments
  better than boney procedures

79
Sports Medicine for Primary Care Physicians

• Pearls to Anterior Knee Pain
• Detailed History
• Accurate Physical Examination
• Focused Initial Rehabilitation Program
• Detailed Sports-Specific Conditioning Program
• Understanding of the Long-Term Need to continue
  rehabilitation
• NO QUICK FIXES

80
Sports Medicine for Primary Care Physicians

• Recommendations for Preventing
• Exercise-Related Injuries in Females
• Women are engaging in sports and fitness
  activities with increasing numbers
• Women participating in sports has grown from
  300,000 three decades ago to 2.7 million today
• Women represent 33 of college athletes and 37
  of US Olympic athletes

81
Sports Medicine for Primary Care Physicians

• 37.4 million women now perform aerobic activity
  on average twice each week
• Unfortunately, research on exercise-related
  injuries in women has not kept up and the true
  incidence and risk factors are not known
• CDC evaluated military personnel for female
  related sports injuries

82
Sports Medicine for Primary Care Physicians

• Injury rates among military females was 1.7 to
  2.2 times higher than males
• Female recruits were less fit upon entering the
  military service
• Low aerobic fitness was found to be the greatest
  risk factor affecting female athletes
• Increased aerobic fitness programs decreased the
  incidence of injuries in recruits when done early
  in basic training

83
Sports Medicine for Primary Care Physicians

• Studies revealed that age was not a strong risk
  factor for injury
• Older athletes modify there degree of intensity
  of exercise and thus limit their risk of injury
• Smoking did influence injury rates with 1.2 times
  higher rate of injury in smokers compared to
  non-smokers
• Reason delayed healing of microtrauma to tissue

84
Sports Medicine for Primary Care Physicians

• Body composition also influenced injury rates in
  females
• Higher Body Mass Index associated with increased
  risk due to extra load placed on body
• Low Body Mass Index also seen with higher risk
  due to lower proportion of muscle relative to
  bodys bone structure, thereby putting greater
  stress on the bones leading to injury

85
Sports Medicine for Primary Care Physicians

• Strategies for Injury Prevention
• Women over 50 should consult their physician
  before beginning an exercise program
• Frequency, Duration, and Intensity of exercise
  should be customized
• Watch for early warning signs such as increasing
  muscle soreness, bone and joint pain, fatigue,
  and decreased performance

86
Sports Medicine for Primary Care Physicians

• When warning signs present, reduce frequency,
  duration, and intensity of exercise until
  symptoms diminish
• If injury occurs, then sufficient time should be
  allowed for recovery and rehabilitation before
  resuming exercise activity
• Women who smoke should stop
• Most importantly, set realistic goals

87
Sports Medicine for Primary Care Physicians

• COX-2 Specific Inhibitors Improved
• Advantages Over Traditional NSAIDs

88
Sports Medicine for Primary Care Physicians

• Role of NSAIDs in treating injuries has been
  based on their ability to inhibit inflammation
  and depress pain via inhibition of the enzyme
  cyclooxygenase
• Cyclooxygenase catalyzes the first two steps in
  the synthesis of prostaglandins
• NSAIDs(COX-1) inhibit prostaglandins but also
  affect other important bodily functions ie.
  Gastric mucosal protection, platelet aggregation

89
Sports Medicine for Primary Care Physicians

• Recent Studies revealed a second gene with
  cyclooxygenase activity (COX-2)
• This gene primarily involved in the inflammation
  and pain cycle whereas the COX-1 is moreso the
  housekeeping enzyme
• Furthermore, COX-2 is inducible in most cells
  that is upgraded in inflamed tissue by cytokines
  and endotoxins to produce PG
• COX-1 is a constitutive enzyme seen in all cells
  including monocytes and platelets

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• This specificity gives the COX-2 inhibitors a
  better and more selective effect on the
  inflammatory cycle without damaging the
  housekeeping effect needed from the COX-1
• Comparative NSAIDs will influence bone and tissue
  metabolism through their effect on PG production
  and effect all aspects of healing both in
  fractures and injured tissue
• COX-2 being inducible, will allow the normal
  cascade mechanism for healing to continue

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• Comparative NSAIDs will effect bone fracture
  healing, bone fusion in spinal fusion surgery, as
  well heterotopic ossification through effect on
  the COX-1 and overall effect on the constitutive
  enzyme needed for housekeeping
• Even though COX-2 effect cytokines seen in
  inflammatory tissue and also the fracture model,
  being inducible, it will block those being
  produced and not those in the normal tissue
  cascade allowing the cycle to continue

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• Celebrex and Vioxx do not inhibit COX-1 and
  thereby do not affect the housekeeping functions
  of COX-1
• Celebrex and Vioxx only affect COX-2 and does not
  disturb the COX-1 in the GI tract and thus
  preserves the effect on the gastric mucosal and
  the protective effect of prostaglandins in the GI
  tract

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• Benefits therefore of COX-2 show a higher safe GI
  profile
• Improved effects on pain and inflammation
• No effect on thromboxane synthesis and therefore
  no influence on platelet aggregation
• No effect on post-operative bleeding

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• For Sports-Related Injuries it offers relief
  from pain and inflammation, rapid onset of
  action, improved quality of life and better
  dosing regimens
• COX-2 inhibitors are effective in treating acute
  and chronic pain including muscle tenderness,
  strains, sprains, and even fractures (potentially
  no effect on new bone formation) excellent effect
  on pain control

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• Use in recent studies on minimally invasive
  orthopaedic procedures reveals positive results
  especially in ACL reconstructions
• Regime proved effective was Vioxx 50mg given the
  morning of surgery and then 50mg daily for 4
  days, then decreased to 25mg daily there after

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• THANK YOU

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Sports Medicine for Primary Care Physicians

• Dr. George Alavanja
• Director, Section of Sports Medicine
• The Orthopaedic, Pediatric Spine Institute
• Crown Point, Indiana

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• Role of COX-2 Inhibitors on influencing bone
  graft arthrodesis in spinal fusion surgery
• Kucharzyk,D and Cook,S. In
  Vivo Controlled Animal Study on the Effect of
  COX-2 Inhibitors on Lumbar Spinal Fusion Surgery
• Tulane University Clinical Research Dept.
• The Orthopaedic, Pediatric Spine Institute