The Employer/ Employee Relationship Kimberley Childress, CPP February 16, 2013.
Marc Childress, MD Self –Renowned Sports Medicine Expert.
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Transcript of Marc Childress, MD Self –Renowned Sports Medicine Expert.
Chest and Abdomen Problems in Athletes
Marc Childress, MDSelf –Renowned Sports Medicine Expert
Rules to live by in Sports Medicine
. A person hears only what they understand
Johann Wolfgang von Goethe
Look wise, say nothing, and grunt. Speech was given to conceal thought.
William Osler
Background
Chest and Abdomen problems frequent primary care complaintsYounger (<35) patients, cardiac causes of chest pain uncommonCauses of trauma increase with athletic participation
Preview
Chest TroublesNo SpineNo Heart
Abdomen TroublesNo PregnancyNo GI specific complaints
Everything else, Fair Game
Runner's Nipples
Noted on 2-16% of marathonersRepetitive friction between shirt and nipple, resulting in painful, erythematous, and crusted nipplesPrevent with petroleum jelly, skin lube or bandage/tape layerTreat with petroleum jelly or bandage/tape layerMay need topical abx
Muscle Strain (Intercostal)
Macro/micro trauma due to unaccustomed or excessive activityUpper body activitiesCoughMinor traumaDiagnosis
Pain BETWEEN ribs, worse with movement or deep inspiration, pain AT area of pressure
Treatment w/ NSAIDS, rest
Rib Fractures
Lucencies fall into one of three groups1) Acute Fracture
Severe Direct TraumaIndirect Trauma – rapid contraction of neck muscles (MVA, lifting, cough, etc.)
2) Stress FractureDifferent patterns seen in first rib vs remainderFirst rib stress fx usually result of ant scalene force (overhead activities – baseball, basketball, tennis, weight lifting, )Others usually result of serratus anterior force (downward stabilizing force – rowing, golf)
3) Congenital Defect – unique to first rib
Acute Fracture - Ribs
Treatment includes pain reliefBEWARE of complications
PneumothoraxSplenic ruptureFlail chest…
Stress Fracture – First Rib
Pain can present in the shoulder, anterior neck, or clavicular regionPain may refer to lateral upper armPain with deep inspirationTenderness possible at:
Superior angle of scapulaSupraclavicular triangleDeep in the axilla
Plain films often (-), consider bone scan, MRI, CT
Stress Fracture -- Ribs
Insidious onset of vague discomfort leading to sharper painPosterior thorax commonRadiation along associated intercostal nerveDeep inspiration, direct palpation, provocative overuse motions painful
Stress Fracture -- Ribs
ManagementPain free rest 4-6 weeksGradual reintroductionMost improved by 8-10 weeks
Rowers usually improved in 4 weeksGolfers 8 weeks
Require scrutiny of technique, underlying bone health concerns (endo, metabolic dz, female athlete triad, steroid use, etc.)
Slipping Rib
Also known as:Rib tip syndromeClicking ribSlipping rib cartilage syndromePainful rib syndromeNerve NippingDisplaced ribsTwelfth rib syndrome
Defined by:Pain in lower chest/abdTender spot on the lower costal marginReproduction of pain with palpation
Slipping Rib (cont'd)
Typical Hx includes intermittent sharp stabbing pain followed by prolonged sorenessNo imaging modalities to ascertain dx, excludes other DxsConsider rest, manipulation, nerve block, local steroid injection, resection of rib end
Mixed literature on prognosis
Prolonged courseOne study with conservative measures showed 70% patients with pain at 8 yearsRemainder became pain free after approx 16 mos.
In series of excision patients (n=17), 82% pain free at 7 days, 100% at 6 weeks
Thoracic Wall Joint Conditions
CostochondritisChest wall pain and tenderness at the costochondral or costosternal jointsLikely inflammatory (positive gallium scan)Unlikely degenerative or traumatic
Tietze’s SyndromeDistinct from above by swelling at tender area
Fracture-dislocation of the Sternocostal Synchondrosis
Precordial Catch
Sharp, stabbing pain in precordial/left parasternal region without radiationOnly last secondsCan be at rest or with mild or moderate exerciseRare above age 35Thought to be have pleural originMay respond to repositioning/stretching
Effort Thrombosis
Thrombosis of the subclavian or axillary veinMost common with repetitive overhead motion- pitchersSxs typically include pain and swelling into the arm, possible numbnessSigns include edema, venous prominenceDx with US or venography
Tx with rest, elevationHeparin followed by coumadin
Pneumothorax
Traumatic vs SpontaneousSpontaneous bleb rupture, sudden compressive force, displaced rib fractureBoth associated with tachypnea, dyspnea, and sudden chest pain
Simple vs TensionShift of mediastinal structures (with both)Tension sees additional tachycardia, neck vein distention, and hypotension.
Pneumothorax (cont'd)
Dx made by quick hx and assessment of signs/sxs
PE may demonstrate decreased breath sounds / hyperresonance on affected sideX-rays can be confirmatory, but suggested tension pneumo should NOT WAIT for films
Tx based on degree and stabilityRapid assistance with needle decompressionTension and signif simple require tube thoracostomy Small (<20%) simple pneumothorax may be treated with close observation
Pulmonary Contusion
Blunt force to lung tissue resulting in edema, hemorrhageChildren more prone given elasticity of chest wall (concurrent decreased risk in rib fx)
Cough, hemoptysis, SOB, and dyspneaDiminished breath sound, ralesFluffy infiltrate on x-raysLimit fluid intake, rest, may need add’l vent support
Cardiac Contusion
Rapid deceleration, compression against sternumCycling, skiing, parachuting, rock climbing, race car driving
Signif cardiac events are rare, most happen within 24 hours
Monitoring to include tele, vitals, and exam to include auscultation and neck vein distention
Initial EKG best predictorPoor prognostic capability with additional testing (CPK, echo, gated pool scans)
Commotio Cordis
Abdominal Wall Injury
Muscular contusion – rest, ice, return once pain freeRectus sheath hematoma – rupture of the epigastric vein or artery
May need surgical evacuation and ligationRecovery and return determined once pain resolved, typically 1 to 2 weeksForces required can easily induce intra-abdominal injuryConsider CT, DPL
Splenic Injury
Can be result of:1) Direct force to abdomen 2) Sudden deceleration tearing the hilum 3) Displacement of left lower rib fracture
Increased risk with increased sizeMononucleosisHematologic dz
Dx made on PE and clinical suspicion, rapid imaging with CTOptions for Operative vs conservative tx based on patient stability, reassuring CBC, and lack of associated injuriesRecovery within 1-2 weeks, avoid contact 3-4 months
Hepatic Injuries
Can be result of:1) Direct blow to abdomen 2) Sudden deceleration 3) Displacement of right lower rib fracture
Increased risk with increased sizeHepatitis
Dx made on PE and clinical suspicion, rapid imaging with CTOptions for Operative vs conservative tx based on patient stability, reassuring CBC, and lack of associated injuriesRecovery within months, avoid contact at least 3-4 months, completely pain free and CT normal
Renal Trauma/In jury
Mechanism, focal pain, and hematuria are most suggestive signs/sxs, but imprecise
Hematuria NOT present in 25% of renal, 40% renal pedicle injuries Flank mass or ecchymosis may be present but often absent
In trauma, high risk suspicion (gross hematuria, micro hematuria w/hypotension or flank mass) should result in CT, possibly IVP
Renal Trauma / Injury (cont'd)
Only injuries with clinical worsening or instability require surgeryMost injuries, even severe, will heal within 6 to 8 weeksMicro hematuria can persist 2 to 4 weeks after injuryDo not confuse / overlook urethral injuries
Sports Hernia
“Athletic pubalgia”“Sportsmen’s hernia”“Osteitis Pubis”“Gilmore’s groin”“Hockey groin syndrome”“Ashby’s inguinal ligament enthesopathy”
Sports Hernia
Dull, diffuse groin painOften radiating to the perineum and inner thigh Typically more intense with athleticUsually chronic in nature
Variable numbers
sports hernia review.pdf
Sports Hernia1992, Malycha and Lovell“. . . .bulge in the posterior wall consistentwith an incipient direct inguinal hernia”.
1995, Simonet et al“Partial or complete tears on the floor of the inguinal ring, at the internal oblique muscle. “The posterior wall and external oblique aponeurosis were intact.
2000, Meyers“loose inguinal floor, a small defect in the external oblique aponeurosis, and thinning or tearing of the rectus abdominis insertion.”
2001, Irshad et al.“isolated tears of the external oblique aponeurosis”
Sports Hernia
2002, Kumar et al.Majority had >1 lesion.
56% - External oblique tear50% - Bulge in the posterior wall 12% - Conjoined tendon disruptions32% had both a tear of the external oblique aponeurosis and a deficiency of the posterior wall, but an intact conjoined tendon. The ilioinguinal and genitofemoral nerves were normal
Sports Hernia
Consider ultrasound and herniography to evaluate for an attenuated abdominal wallMRI to evaluate pubic bone edema, attenuated musculature, and edema within pathologic tissueRule out confounders to the best of your abilityFind a believing consultantsports hernia review.pdf
Summary
Musculoskeletal injuries common in truncal areaKnowledge of pertinent anatomy is criticalMedical common sense rules the dayMaintain vigilance for rare but potential life-threatening situationsRemember my uncle