14 Chang MedicalProblems - UCSF CME€¦ · 3odlq ;5 ilopv fhuylfdo ule fdooxv iurp d fodylfoh...

1

Cindy J. Chang, M.D.UCSF Clinical ProfessorPrimary Care Sports MedicineDepts. of Orthopaedics and Family & Community Medicine

Medical Problems in the Young Athlete

Cases from My Clinic

Cindy J. Chang, M.D.

2

Disclosure

I have no financial disclosures or conflicts of interest in relation to this presentation

Ossur Americas: I presented an independent lecture on knee osteoarthritis

Case #1:

17 yo female w/ intermittent R shoulder pain since 2016. She was in cheer in high school but denies any injury from this. She denies any known injury. Works as server at restaurant. Her pain is posterior in upper shoulder and when she has pain she will also have numbness radiating down her right medial arm. Denies weakness.

5/10 Pain Scale

Aching and sharp, and constant

Night pain that wakes patient up: yes

Previous treatments include: nothing

Has not tried anything that makes the pain better; has not noted anything that makes the pain worse

3 Medical Problems in the Young Athlete: Cases from My Clinic – Cindy J. Chang MD

PQRST: Provocation and Timing

As an athlete:- When did injury occur?

- What activities cause/increase the symptoms?

As a student/worker:- When did symptoms start?

- What maneuvers/positions cause/increase the symptoms?

4Cindy J. Chang, M.D.

2


PQRST: Quality and Radiation


Case #1

C-spine FROM, no pain, neg Spurlings

No erythema, ecchymoses or deformity noted of shoulder girdle

No mm atrophy

R shoulder FROM w/o pain. Motor 5/5 w/o pain. Sensory intact.

No pain to palpation along the clavicle, scapula

Tenderness to palpation over supraclavicular space/first rib, just lateral to R side of C7, coracoid-clavicular interval

Positive Adson's test bilaterally

Positive Roos test duplicating ulnar nerve pain


8

Areas of Compression:

- Costoclaviculartriangle

- Interscalene triangle

- Subcoracoid space


3

Classification of Thoracic Outlet Syndrome

1. By Affected structure:

a. Neurogenic or vascular (arterial or venous) or a combination

2. By Cause of compression:

a. Scalene

b. Cervical rib

3. By Event:

a. Trauma

b. Repetitive stress

c. Posture

9

Twaij H et al. BJSM 2013


Vascular TOS

Rare; involves subclavian artery and/or vein

- More likely to occur in younger patients; vigorous overhead arm activity

- Venous obstruction Can be secondary to thrombosis, Paget-von Schrötter syndrome

Diffuse arm, forearm, or hand pain (“tourniquet”); UE swelling; venous distention

- Arterial obstruction color changes; claudication; diffuse arm, forearm, or hand pain

Due to arterial collateral blood flow, initial symptoms may be mild (arm ache and fatigue, esp. after overhead activity)


Neurogenic TOS

Compression of brachial plexus; pure neurogenic presentation also rare

- Also tends to affect those who perform overhead and repetitive activities

- Can present with

painless atrophy of intrinsic muscles of hand

difficulty grasping a racket or ball due to weakness

report of sensory loss or paresthesias

- Pain usually mild


Nonspecific-type or Functional/Dynamic TOS

Pain in the arm or both arms, scapular region, and cervical region

Dynamic transient mechanical restriction

What event caused/causes/worsens the symptoms?

- Traumatic event (eg, MVA, fall)

- Computer work

- Mobile device


4

Nonspecific TOS Signs and Tests

Weakness and decreased sensation, tingling, heaviness, fatigue, achiness, coolness

Non-focal and non-radicular findings

Diffuse UE pain w/ or w/o guarding

Poor posture

Tenderness over coracoid, pectoralis mm, scalenes; tightness of mm

Fullness in supraclavicular space from elevated rib


Special TOS Tests

Adson’s maneuver - Neck extended and rotated to Affectedside w/ Arm at side while deeply inspiring and holding the breath, pulse checked

Wright’s test – (airplane) Affected arm slowly abducted and externally rotated, pulse checked, while taking a deep breath

Roos stress test – (Raise the Roof) Shoulder abducted above the head, externally rotated and repetitive opening and closing both hands into fists for at least 1 minute

Tests considered + if reproduce symptoms and/or a decrease in pulse detected, or paresthesias, or can’t complete Roos

Cindy J. Chang, M.D.14

Nord KM et al. Electromyog Clin Neurophys 2008

Special TOS Signs and Tests


TOS Diagnostic Testing

Plain XR films: cervical rib, callus from a clavicle/upper rib fx, apical tumor

Venous US studies, Doppler US, angiogram, venogram, CT/CTA, NCS/EMG, NeuroMSK US

MRI/MRA: brachial plexus anatomy, subclavian vein anatomy, vascular occlusion/compression- Positional scans with arm in dynamic position

to reproduce sx can improve validity of tests

- MRI alone: 41% sensitivity, 33% specificity

Neg predictive value 4%


Lewis M et al. J Vasc Diag 2014Singh VK et al. J Ortho Surg 2014

5

Case #1


17

Case #1

6 wk follow-up:

- Pain is worse and now has coldness in the R arm down ulnar side of arm to ring and pinky fingers, still numbness. Denies swelling or blue tint in arm.

- PT helping with decreased pain during walking

- Also quit job to focus on school


18


19

Case #2

15 yo female, referred to see me for second opinion by pedsortho colleague

8 months prior first experienced left iliac crest pain during dance class- Can’t recall injury, was just standing when first had pain

Then during summer intensive dance class (12 hrs a week, 3-5 hr max a day, for 4 wks) much worse, and right ant superior iliac crest began hurting as well. Had to quit dance.- No relief with ice, stretching, NSAIDs


6

Case #2

Hx fractured foot, stress fx foot left MT, and achillestendonitis left ankle. Also shin splints bilat with dance. - Injuries since 11

yoa

Mom says has had slow healing esp the achilles injury


Case #2


Case #2


Case #2


Vit D 22.2; 2000 IU BID started

Was on crutches partial weightbearing x 3 wks, then wheelchair to totally unload x 4 wks, then back to crutches

Started using bone stimulator

I reviewed her chart

7

Case #2


Summary of findings:

12/15/11: had left 5th MT base fracture, treated with cast.

2/22/12: saw Dr. P for left achilles pain that developed since cast off.

4/4/12: f/u visit and per PT rec had been in walking boot already x 3 wk.

5/3/12: no real improvement, so MRI ordered.

5/18/12 MRI of left ankle- Mild swelling as well as some fluid around a portion of the flexor hallucis longus tendon. Achilles tendon is normal.

5/24/12: completely immobilized in walking cast x 4 wks.

Case #2


Summary of findings (cont.):

6/19/12-10/11/13: began to see Dr. S. No notes accessible in Epic.

8/23/12 MRI of left foot- Stress injury and/or nondisplaced fracture of the proximal right 2nd metatarsal bone

11/29/12 - MRI left foot for lat foot pain - Resolving edema in the metatarsal bone of the 2nd toe. - Interval development of marrow edema in the lateral calcaneus

adjacent to the calcaneal cuboid articulation. Minimal adjacent soft tissue edema. May be post traumatic in etiology. Alternatively, this appearance may be on the basis of altered weight bearing mechanics.

Case #2



5/20/14: visit with Dr. S; still in formal PT once a month, still unable to do gymnastics, hurts with running. Dr. D second opinion, no good solns. MRI ordered.

6/19/14 - MRI left foot - Minimal ankle joint effusion with minimal synovial thickening, nonspecific finding. Otherwise normal MRI of the foot.

Case #2



7/1/14 visit with Dr. S: has had acupuncture, and has drawn labs. "Her pain bothers her with impact from running and jumping. She has had an extensive work-up that is negative for any specific pathology. She has also seen another orthopaedic surgeon for second opinion and no cause for her foot pain was found. MRI is negative for pathology in the area of her symptoms. I have done an extensive work-up and do not have a explanation for her pain."

10/8/14: visit with dr. K, for follow up of left leg and foot pain. Note never able to return to gymnastics. Now left leg pain x 4 months, now in dance.

xrays neg and back in PT for this until 10/9/15.

10/9/15: first mention of iliac crest pain to PT. She was to have been discharged for her shins.

8

Case #2

Summary of chart review

- Long bouts of pain with no identifiable cause

- For her last shin splints dx, was seen by PT for one year, before the onset of this iliac crest pain Although pain in hips started in July 2015, she did not tell her PT until

October 2016.

- Ordered labs to evaluate bone metabolism and evaluate for rheumatological/inflammatory process,


Case #2


Case #2


Follow up visit following week

- Labs reviewed; negative

- She denies any food aversions or avoidances. Weight has been stable. Has not grown for at least one year. Is same height as her parents. 10 menstrual cycles in the last 12 months.

- Is an only child at home, has older bro and sis in college.

- Try back brace to support obliques/abdom mm to see if will help with pain

Case #2


Follow up visit one month later

- Brace helps with back achiness but not with iliac crest pain

- Since getting the brace, she has been getting HA HA occas associated with nausea, sometimes photophobia. No fam hx

migraines. No double vision. She uses ipad. Doesn't have a laptop or desktop.

Resolves with ibuprofen

HA at back of neck/top of head/more throbbing.

9

Case #2


Follow up visit 6 wks later

- Still using bone stimulator

- Stopped wearing back brace because of the HA (after a month). It did help her back pain.

- After she stopped the brace the back pain never returned and HA resolved.

- Gradually improving, progress walking/swimming

Case #2


Follow up visit 6 wks later

- 0/10 pain with sitting and walking; can tolerate all PT exercises

- Running on Alter G, 60% body weight

- Resumed cheer team but jumps caused iliac crest pain to hurt but quickly resolved

- Recently pulled left hamstring

- Long car ride to go camping caused low back soreness

Case #2


Follow up visit 3 months later when her back and “hips” flared

- Got shin splints again early fall season as was taking dance 2x/wk and cheer 2x/wk 8-10 hr/wk total plus FB game coverage, plus dance class every day 60 min a day

- Has rested 3 wks since end of FB season, improving

- Wants to resume bone stimulator

- Has begun seeing a therapist for anxiety

Follow up visit 1 month later- May have tweaked low back during stretching

- On exam, for the first time she has SI joint pain

Case #2


10

Case #2

Negative sacroiliitis


Case #2

Referral to rheumatologist

Hx concerning for HLA B27 positive Enthesitis Related Arthritis (ERA)- Sacroiliitis would warrant anti-TNF therapy.

- Start a standing NSAID to help with current pain from apophysitis.

- Discussed potential association of ERA with symptomatic uveitis

refer to the eye doctor for uveitis screening at baseline, once yearly

Symptoms increased after this visit, to include nausea, abdominal pain, fatigue, HA, light sensitivity- Dx with pain overlay syndrome by psychologist

Has been dependent on PT x 5 yrs


Case #3

14 yo 9th grade female XC athlete (first year running) at very competitive high school (team consistently top-ranked in state)

Presents with pain in L buttocks region, still ran in race 2 d later

Tried to X-train on stationary bike; pushing down on pedal hurt

Saw pediatrician and referred to PT; first visit was approx 1 month after onset of injury.

What else would you like to know?


Case #3 – Additional History

Onset of menses at age of 13 but irregular- 3 cycles in past 12 months

- No menses in last 4 months

Runs all year round with 2 week break. - Runs 14 hours a week

Diet

- Older brother has nut allergy

- Mom hx of breast cancer so no soy products in house

Family Hx- Mom has osteopenia

- Maternal aunt scoliosis


11

Case #3 – Physical Exam

Vital signs- 5’3”

- 111# 12 oz

- BMI 21

No pain with hip ROM

No pain with mm testing including resisted hip extension and knee flexion

Vague pain on palp of left ischial tuberosity

Neg hop test


Imaging studies

Case #3

Menses resumed 1 month after she stopped running

Labs- Vit D – 24.2

- Ferritin 28

Nutrition referral

Running analysis


Case #3

8 months later, L lower leg pain

Training for cross country season for past 2 months (early summer), with gradually increasing mileage, now 30 – 40 miles/week

Hurts front of the lower leg, worse with running, better with rest.

Physical therapy and taping for shin splints have not helped.

12


Vital signs- Height 5’3”

- Weight 105#

- BMI 18.6

Tender anterior cortex LLE approximately 8 cm proximal to the medial malleolus

Pain with double and single leg hop

45


46


47

Female Athlete Triad (The Triad)

Healthy energy status

Healthy menstrual

cycles

Healthy bones

Low energy availability with

or without eating d/o

Osteoporosis Amenorrhea

Low bone density

Suboptimal energy availability

Irregular menses

OPTIMAL HEALTH

PATHOLOGY

Nattiv A et al, ACSM Position Stand, 2007.

The interrelationships between energy availability, menstrual function, and bone mineral density

13

Relative energy deficiency in sport (RED-S)

Mountjoy M et al. The IOC consensus statement: beyond the Female Athlete Triad--Relative Energy Deficiency in Sport (RED-S). Br J Sports Med. 2014 Apr;48(7):491-7.

Low energy availability (EA) is key to the Triad and RED-S

Clues:- BMI

High risk: < 17.5 or < 85% expected body weight in adolescents

Mod risk: 17.6-18.4 or between 85-90% expected

- Recent weight loss

- Disordered eating

Sports dietician or exercise physiologist can help assess EA very scientifically

A stable body weight should not be interpreted as adequate EA- An athlete may be in energy balance at a stable, low, body weight

but with suppressed physiologic function

Joy E et al. 2014 female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad. Curr Sports Med Rep. 2014.

Prevalence of the Triad

Higher in sports where - Leanness gives competitive advantage

- Body conforming uniforms required

Sports- Long distance running

- Gymnastics

- Swimming

- Diving

Joy EA, Nattiv A. Clearance and Return to Play for the Female Athlete Triad: Clinical Guidelines, Clinical Judgment, and Evolving Evidence. Curr Sports Med Rep. 2017 Nov/Dec;16(6):382-385.

Triad screening questions

Menstrual periods

- LMP?

- # in past 12 months?

- Age of menarche

- Taking any female hormones, OCPs?

Bone health

- Have you ever had a stress fracture?

- Have you ever been told you have low bone density?

Energy availability

- Do you worry about your weight?

- Are you trying to or has anyone recommended you gain or lose weight?

- Are you on a special diet or do you avoid certain foods?

- Have you ever had an eating disorder?

De Souza MJ et al. 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad. Br J Sports Med. 2014 Feb;48(4):289.

14

Amenorrhea work-up


Functional hypothalamic amenorrhea

Due to low energy availability

Diagnosis of exclusion

Decreased GnRH decreased LH, FSH decreased estrogen

Joy E et al. 2014 female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad. Curr Sports Med Rep. 2014.

Should this athlete have a DEXA?Indications for DEXA testing in athletes

≥ 1 high-risk triad risk factor

• DSM-V diagnosed eating disorder

• BMI < 17.5, < 85% estimated weight or recent weight loss ≥ 10% in 1 month

• Menarche ≥ 16 years of age

• Currently with < 6 menses over 12 months

• 2 prior stress reactions/fractures, 1 high-risk stress fracture/reaction or a low energy atraumatic fracture

• Prior z-score < -2.0

• ≥ 2 moderate-risk triad risk factors

• h/o or current disordered eating ≥ 6 months

• BMI 17.5-18.5, 85-90% estimated weight or recent weight loss 5-10% in 1 month

• Menarche age 15-16 years

• H/o 6-8 menses over 12 months

• 1 prior stress reaction/fracture

OR

Joy E et al. Curr Sports Med Rep. 2014.

DEXA

If < 20 y/o- Scan whole body or total body less head in addition to lumbar

spine BMD

If ≥ 20 y/o - Scan femoral neck and lumbar spine

In either case for premenopausal girls / women- use the Z-score which compares to age-matched controls rather

than T-score which compares to peak BMD.

Lowest score guides treatment

Joy EA, Nattiv A. Clearance and Return to Play for the Female Athlete Triad: Clinical Guidelines, Clinical Judgment, and Evolving Evidence. Curr Sports Med Rep. 2017 Nov/Dec;16(6):382-385.

15

How do you interpret her DEXA?Definition of low BMD in premenopausal women

Z-score ≤ -2.0: below the expected range for age

Z-score > -2.0: within the expected range for age

HOWEVER

If female athlete in weight-bearing sport- Z-score < -1.0: below the expected range for age (low BMD) per

American College of Sports Medicine

Osteoporosis- Z-score ≤ -2.0 and

- Clinically significant fracture history (long bone fracture of leg or vertebral compression fracture or 2 or more long bone fractures of upper extremities)

Can this athlete with female athlete triad safely return to play?Female athlete triad: Cumulative risk assessment

Mary Jane De Souza et al. Br J Sports Med 2014;48:289.

Can this athlete with female athlete triad safely return to play?Female Athlete Triad: Clearance and Return-to-Play Guidelines by Medical Risk Stratification.

Mary Jane De Souza et al. Br J Sports Med 2014;48:289.

*Cumulative Risk Score determined by summing the score of each risk factor (low, moderate, high risk) from the Cumulative Risk Assessment.

Female athlete triad treatment: Increase EA

Increase dietary energy intake

Decrease exercise

Has been shown to restore menses

Has been shown to increase bone density

May benefit from nutritionist, psychiatrist, psychologist

Gradual approach over months

Team physician may initiate a contract esp in athletes in moderate – high risk groups that outlines the criteria needed for return to play.

Joy E et al. 2014 female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad. Curr Sports Med Rep. 2014 Jul-Aug;13(4):219-32.

16

Treatment for low BMD

Weight gain and subsequent resumption of menses

Calcium-rich foods for goal 1000-1300 mg/d

Vitamin D 600 IU/d for goal serum level 32-50 ng/ml

Weight-bearing exercise? - Further studies needed to weigh risks/benefits in athletes with low

BMD (fx risk)

Joy E et al. Curr Sports Med Rep. 2014 Jul-Aug;13(4):219-32.

Treatment for low BMD

Pharmacologic tx: - if lack of response at least 1 year and if new fractures occur during

nonpharm management.

Combined oral contraceptive pill:- not associated consistently with improved BMD in athletes with

amenorrhea

Transdermal estrogen with cyclic progesterone: - increases BMD in adolescent girls with anorexia. Needs more

investigation for use in the Triad.

Joy E et al. Curr Sports Med Rep. 2014 Jul-Aug;13(4):219-32.

3 components of the triad recovery at different rates


14 Chang MedicalProblems - UCSF CME€¦ · 3odlq ;5 ilopv fhuylfdo ule fdooxv iurp d fodylfoh...

Documents

Transcript of 14 Chang MedicalProblems - UCSF CME€¦ · 3odlq ;5 ilopv fhuylfdo ule fdooxv iurp d fodylfoh...