Transcript 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’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’s”
“Musculoskeletal Overuse
Syndromes”
“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
“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
“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
“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
“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
“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
“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
“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.
“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
“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
“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-throughgreatest stress on physis at this time
Radiographs reveal widening of the proximal
humeral physis
“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
“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
“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
“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
“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
“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
“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
“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
“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
“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
“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
“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
“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
“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
“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
“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
“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 xrays with Merchant view to see patellar
alignment and position
Treatment is symptomatic via rest,
NSAID, physical therapy and sometimes
bracing
“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
“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
“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
“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
“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 patellofemoral contact force during flexion in the
presence of weak quadriceps and minor
trauma
“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
“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
“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
“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
“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
“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
“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
“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 sportsspecific training program (return 2-8 wks)
“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
“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
“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
“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)
“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
“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
“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
“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
“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
“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
“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
“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
“Sports Medicine for Primary
Care Physician’s”
“Female Sports Related Injuries”
Shoulder Instability
Preventing Knee Injuries
Patellofemoral Problems in Women
Preventing Exercise-Related injuries
“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
“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
“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
“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
“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)
“Sports Medicine for Primary
Care Physician’s”
Atraumatic Instability: typically a microinstability 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
“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
“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
“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
“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)
“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
“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
“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 costeffective means to reduce injury
“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
“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
“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
“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
“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
“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
“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
“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 realignments better than boney procedures
“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
“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
“Sports Medicine for Primary
Care Physician’s”
37.4 million women now perform aerobic
activity on average twice each week
Unfortunately, research on exerciserelated 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
“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
“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
“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
“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
“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
“Sports Medicine for Primary
Care Physician’s”
“COX-2 Specific Inhibitors: Improved
Advantages Over Traditional NSAIDs”
“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
“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 COX1 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
“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
“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
“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
“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
“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
“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
“Sports Medicine for Primary
Care Physician’s”
THANK YOU
“Sports Medicine for Primary
Care Physician’s”
Dr. George Alavanja
Director, Section of Sports Medicine
The Orthopaedic, Pediatric & Spine Institute
Crown Point, Indiana
“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