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“Sports Medicine for Primary Care Physician’s” . Dr. Donald W. Kucharzyk The Orthopaedic, Pediatric & Spine Institute Crown Point, Indiana. “Sports Medicine for Primary Care Physician’s”. Pediatric Athletic Sports Related Injuries

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sports medicine for primary care physician s

“Sports Medicine for Primary Care Physician’s”

Dr. Donald W. Kucharzyk

The Orthopaedic, Pediatric & Spine

Institute

Crown Point, Indiana

sports medicine for primary care physician s2
“Sports Medicine for Primary Care Physician’s”
  • Pediatric Athletic Sports Related Injuries
  • Female Athletic Sports Injuries
  • Preventing Sports Injuries in Female Athletes
  • COX-2 Specific Inhibitors: Emerging Role in Sports Medicine
sports medicine for primary care physician s3
“Sports Medicine for Primary Care Physician’s”

“Musculoskeletal Overuse

Syndromes”

sports medicine for primary care physician s4
“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”
  • 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 program’s: sudden increases or changes
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“Sports Medicine for Primary Care Physician’s”
  • Overuse treatment protocol involves five phases:
  • Identify risk factors
  • Modify offending factors
  • Institute pain control
  • Undertake progressive rehabilitation
  • Continue maintenance to prevent re-injury
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“Sports Medicine for Primary Care Physician’s”

“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
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”
  • Standard radiographs are not helpful because early phase stress fractures are radiographically silent
  • Bone Scan’s 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 Physician’s”
  • 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.
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“Sports Medicine for Primary Care Physician’s”

“Stress Injuries of the Growth Plate”

  • Must be aware that chronic stress injuries can cause physeal damage
  • Runner’s show this manifestation in the distal femur and proximal tibia--attention to history, clinical exam, and xray evaluation important..confused with neoplasm
  • Area’s Affected Include: Proximal Humerus commonly seen in Pitcher’s
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”

“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 Physician’s”
  • 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 pitcher’s development of skill and control, then with maturity develop speed and velocity
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“Sports Medicine for Primary Care Physician’s”

“Little League Elbow”

  • Medial elbow pain in tennis player’s, javelin thrower’s, and football quarterback’s
  • 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 Physician’s”
  • 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 Physician’s”
  • 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

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“Sports Medicine for Primary Care Physician’s”

*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 Physician’s”

“Panner’s 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 Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”

“Iliac Apophysitis”

  • Iliac crest tenderness on palpation and muscular contraction seen primarily in adolescent long distant runner’s
  • No local trauma but history of extensive intensive training programs
  • Radiographs are normal
  • Treatment is rest (4-6weeks), ice, NSAID, progressive return to sports
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“Sports Medicine for Primary Care Physician’s”

“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
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”

“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 Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”

“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, athlete’s with knee pain should have the hip evaluated too
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”

“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 Down’s 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
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”

“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 3:1
  • Seen in the knee but can also be seen in the ankle involving the talus and the patella
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“Sports Medicine for Primary Care Physician’s”
  • 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 lesion’s from silent “chronic” lesions
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“Sports Medicine for Primary Care Physician’s”
  • Treatment geared to eliminate the pathologic process and clinical condition via repair or resection of the lesion
  • Chronic lesion’s loose bodies require removal arthroscopically and debridement of the bed
  • Acute lesion’s require drilling of the bed and fixation arthroscopically to allow the lesion to heal
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”

“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
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”

“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
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“Sports Medicine for Primary Care Physician’s”

“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
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“Sports Medicine for Primary Care Physician’s”

“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
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“Sports Medicine for Primary Care Physician’s”
  • 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)
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“Sports Medicine for Primary Care Physician’s”

“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
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”

“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
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“Sports Medicine for Primary Care Physician’s”
  • 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)
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“Sports Medicine for Primary Care Physician’s”

“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
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”

“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
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“Sports Medicine for Primary Care Physician’s”

“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
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”

“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
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“Sports Medicine for Primary Care Physician’s”

“Female Sports Related Injuries”

  • Shoulder Instability
  • Preventing Knee Injuries
  • Patellofemoral Problems in Women
  • Preventing Exercise-Related injuries
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“Sports Medicine for Primary Care Physician’s”

“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
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”
  • 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)
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”

“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
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“Sports Medicine for Primary Care Physician’s”
  • 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)
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“Sports Medicine for Primary Care Physician’s”

“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
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“Sports Medicine for Primary Care Physician’s”

“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
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”

“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 body’s ability to maintain homeostasis
  • Factors influence: activity changes, training errors, flexibility deficits, and weakness
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“Sports Medicine for Primary Care Physician’s”
  • Clinical History will determine if the patient’s 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
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”
  • 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 term…secondary deterioration of muscles
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”

“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
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“Sports Medicine for Primary Care Physician’s”

“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
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”
  • 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 smoker’s compared to non-smoker’s
  • Reason: delayed healing of microtrauma to tissue
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“Sports Medicine for Primary Care Physician’s”
  • 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 body’s bone structure, thereby putting greater stress on the bones leading to injury
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“Sports Medicine for Primary Care Physician’s”

“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
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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”

“COX-2 Specific Inhibitors: Improved

Advantages Over Traditional NSAIDs”

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“Sports Medicine for Primary Care Physician’s”
  • 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
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“Sports Medicine for Primary Care Physician’s”
  • 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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“Sports Medicine for Primary Care Physician’s”
  • 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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“Sports Medicine for Primary Care Physician’s”
  • 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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“Sports Medicine for Primary Care Physician’s”
  • 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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“Sports Medicine for Primary Care Physician’s”
  • 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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“Sports Medicine for Primary Care Physician’s”
  • 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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“Sports Medicine for Primary Care Physician’s”
  • 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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“Sports Medicine for Primary Care Physician’s”

Dr. George Alavanja

Director, Section of Sports Medicine

The Orthopaedic, Pediatric & Spine Institute

Crown Point, Indiana

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“Sports Medicine for Primary Care Physician’s”
  • 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