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261-280 of 356 results by Brian Corwell
Patellar tendonitis aka jumpers knee
Activity related knee pain due to degenerative, micro injury rather than an inflammatory process
Up to 20% in jumping athletes
Anterior knee pain during or after activity
Bassett Sign:
a) Tenderness to palpation with knee in full extension (patellar tendon relaxed)
b) No tenderness with knee in flexion (patellar tendon tight)
Return to Play After Infectious Mononucleosis (IM)
-Long incubation period make it difficult to determine source or onset
Presentation often atypical with nothing more than fatigue, decreased energy or decreased athletic performance.
DDX: Herpes simplex, HIV, CMV, toxo and strep (simultaneous infection may be seen in up to 30%)
Classic 3 to 5 day prodromal period (malaise, fatigue, anorexia)
Symptoms then progress into the classic “triad” of IM
Fever, pharyngitis, lymphadenopathy (esp. posterior cervical nodes)
May also have posterior palantine petechiae ( of cases), jaundice, exudative pharyngitis, rash and splenomegaly)
Rash (10% to 40%), transient, generalized maculopapular, petechial or urticarial)
Most commonly seen in patients treated with PCN antibiotics
Splenomegaly is an important complication in the athletic population
Mononucleosis makes the spleen susceptible to rupture (traumatic or spontaneous)
- Lymphocytic proliferation enlarges the spleen beyond protection from the ribs
- Physical examination has been shown to be unreliable for determining splenomegaly
- Highest risk is in the first 21 days (rare after 28 days)
Ultrasound is the modality of choice
-Splenomegaly peaks at 2 to 3 weeks and resolves in the majority between 4 to 6 weeks
Return to play is generally allowed after 4 weeks from diagnosis in the absence of splenomegaly and resolution of symptoms.
Cervical Cord Neuropraxia (CCN)
A concussion of the spinal cord as a result of an on-field collision.
A transient motor and/or sensory disturbance, lasting less than 24 hours.
A distinct and separate entity from spinal cord injury resulting in quadriplegia
Incidence 7.3 per 10,000 athletes
Approx. 50% of players experiencing CCN who return to play, have a second episode
The risk of this second episode is inversely proportional to the size of the cervical bony canal
Athletes with narrow canal diameter are more likely to have a 2nd episode
Those with normal canal diameter (14 mm on MRI) have a 5% risk
Those with a narrow canal (9 mm or less)) have a greater than 50% risk.
Whether repeat episodes lead to permanent spinal cord injury is unknown
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Football helmets
A review of head and neck injuries from football from 1959 to 1963 found the rates of intracranial hemorrhage /intracranial death were 2-3X higher than the rates of cervical spine fracture/dislocation or cervical quadriplegia. In contrast, a study of football injuries from 1971 to 1975, revealed a dramatic reversal in rates. Cervical injuries now exceeded the rate of ICH by 2-4X.
A 66% reduction in ICH
A 42% reduction in craniocerebral deaths
A 204% increase in cervical spine fractures and dislocations
The shift was attributed to the modern football helmet, whose superior protection promoted “spearing” (headfirst tackling technique). Spearing involves hitting with the crown of the helmet leading to axial loading of the spine. Spearing accounted for 52% of the quadriplegia injuries from 1971 to 1975. Research by Joesph Torg, M.D., resulted in rule changes that led to an immediate 50% reduction in quadriplegia in NCAA football.
As a parent, coach or team physician, teach and enforce proper form and protect our young athletes.
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Happy Memorial Day! With all the recent attention in the news about swimming and drowning I thought I would share this article
The Instinctive Drowning Response—so named by Francesco A. Pia, Ph.D., is what people do to avoid actual or perceived suffocation in the water. And it does not look like most people expect. There is very little splashing, no waving, and no yelling or calls for help of any kind. To get an idea of just how quiet and undramatic from the surface drowning can be, consider this: It is the No. 2 cause of accidental death in children, ages 15 and under (just behind vehicle accidents)—of the approximately 750 children who will drown next year, about 375 of them will do so within 25 yards of a parent or other adult. In some of those drownings, the adult will actually watch the child do it, having no idea it is happening.* Drowning does not look like drowning—Dr. Pia, in an article in the Coast Guard’s On Scenemagazine, described the Instinctive Drowning Response like this:
- “Except in rare circumstances, drowning people are physiologically unable to call out for help. The respiratory system was designed for breathing. Speech is the secondary or overlaid function. Breathing must be fulfilled before speech occurs.
- Drowning people’s mouths alternately sink below and reappear above the surface of the water. The mouths of drowning people are not above the surface of the water long enough for them to exhale, inhale, and call out for help. When the drowning people’s mouths are above the surface, they exhale and inhale quickly as their mouths start to sink below the surface of the water.
- Drowning people cannot wave for help. Nature instinctively forces them to extend their arms laterally and press down on the water’s surface. Pressing down on the surface of the water permits drowning people to leverage their bodies so they can lift their mouths out of the water to breathe.
- Throughout the Instinctive Drowning Response, drowning people cannot voluntarily control their arm movements. Physiologically, drowning people who are struggling on the surface of the water cannot stop drowning and perform voluntary movements such as waving for help, moving toward a rescuer, or reaching out for a piece of rescue equipment.
- From beginning to end of the Instinctive Drowning Response people’s bodies remain upright in the water, with no evidence of a supporting kick. Unless rescued by a trained lifeguard, these drowning people can only struggle on the surface of the water from 20 to 60 seconds before submersion occurs.”
This doesn’t mean that a person that is yelling for help and thrashing isn’t in real trouble—they are experiencing aquatic distress. Not always present before the Instinctive Drowning Response, aquatic distress doesn’t last long—but unlike true drowning, these victims can still assist in their own rescue. They can grab lifelines, throw rings, etc.
Look for these other signs of drowning when persons are in the water:
- Head low in the water, mouth at water level
- Head tilted back with mouth open
- Eyes glassy and empty, unable to focus
- Eyes closed
- Hair over forehead or eyes
- Not using legs—vertical
- Hyperventilating or gasping
- Trying to swim in a particular direction but not making headway
- Trying to roll over on the back
- Appear to be climbing an invisible ladder
So if a crew member falls overboard and everything looks OK—don’t be too sure. Sometimes the most common indication that someone is drowning is that they don’t look like they’re drowning. They may just look like they are treading water and looking up at the deck. One way to be sure? Ask them, “Are you all right?” If they can answer at all—they probably are. If they return a blank stare, you may have less than 30 seconds to get to them. And parents—children playing in the water make noise. When they get quiet, you get to them and find out why.
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Risk Modifiers for Concussion and Prolonged Recovery
A history of prior concussion is a risk factor for future concussion (>2x risk).
For individual sports, boxing has the highest risk.
For team sports, football, ice hockey and rugby have the highest risk.
Women’s soccer confers the highest risk for female athletes.
Younger age confers increased risk.
Female sex confers higher risk when comparing similar sports with similar rules.
Those with migraine headaches may be at increased risk.
Risk of prolonged concussion
Most athletes have symptom resolution within one week
Post traumatic amnesia (both retrograde and anterograde) predict increased number and longer duration of symptoms.
Younger age also predicts pronged recovery.
Other studies have found associations with headache lasting greater than 60 hours, fatigue, “fogginess,” or greater than 3 symptoms at initial presentation. Cognitive studies have identified deficits in visual memory and process speed as predictors of prolonged recovery.
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Acetaminophen spent much of 2013 being chased by paparazzi and sharing magazine covers with Miley Cyrus. What a fall from stardom after becoming known as the pain reliever “hospitals use most,” and the one, “recommended by pediatricians.” Slogans we know well based on $100 million/year spent on advertising.
Approximately 150 patients a year die from unintentional acetaminophen poisoning averaged over the past 10 years. From 2001 to 2010, annual acetaminophen-related deaths amounted to about twice the number attributed to all other over-the-counter pain relievers combined,
The FDA sets the maximum recommended daily dose of acetaminophen at 4 grams, or eight extra strength acetaminophen tablets.
Ingestion of 150 mg/kg or approximately 10g for a 70 mg individual reaches the toxic threshold for a single ingestion. The toxic threshold decreases in cases of chronic ingestion.
Patients who “unintentionally” overdose have been found to take just over 8g per day (almost double the recommended maximum). This is unlikely due to taking one extra 325mg tablet once or twice.
Before we all go on a mad NSAID prescribing binge, let's all be aware of the dangers, educate our patients and allow Acetaminophen to walk the red carpet again.
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Sports Hernia/Athletic pubalgia
Hx: Gradually increasing lower abdominal/proximal adductor pain. Usually activity related, resolves with rest. Frequent return despite rest when sports activity resumes.
Most common in athletes who perform cutting/maneuvers in addition to frequent acceleration/deceleration. Think ice hockey and soccer.
Bilateral symptoms not uncommon.
PE: Resisted sit up with palpation of the inferolateral edge of the distal rectus may recreate symptoms. Similarly, resisted hip adduction may elicit symptoms.
If for no other reason than to make the diagnosis harder to make, valsalva induced pain may also occur.
Fluoroscopic guided injections can be helpful to isolate the site of pain generation.
First line therapy is rest, non-narcotic analgesia and physical therapy.
With surgery, >80% return to pre injury level of play.
http://atlantasportsmedicine.com/orthopedic-surgeon/wp-content/uploads/2009/11/groin-injuries.jpg
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Ankle Syndesmosis Injuries are also called high ankle sprains as they involve trauma to the ligaments above the ankle joint
Most ankle sprains are lateral ankle sprains. High ankle sprains are relatively uncommon.
Usual mechanism: External rotation injuries
Exam: Tenderness at the syndesmosis and compression of the tib/fib at the mid calf level causing syndesmosis pain (squeeze test)
Median recovery time is almost 4 times as long as a lateral ankle sprain 62days vs. 15days
Emergency department care is similar tto that of other ankle sprains but the added benefit of patient education and advice may improve overall care and follow-up.
Herpes Gladiatorum in Wrestlers
HSV causes non genital cutaneous infections primarily in wrestlers, commonly called herpes gladiatorum (HG)
Annual incidence in NCAA wrestlers is 20% to 40%
Most common cutaneous infection leading to lost practice time (40.5% of all infections)
Transmission is skin to skin.
Incubation period is 4 to 7 days from exposure. Healing usually occurs within 10 days after the initial lesion (without scaring).
Appearance: Numerous grouped uncomfortable (painful) vesicles/pustules on an erythematous base…evolve into moist ulcerations, followed by crusted plaques. Lesions typically get abraded during competition therefore may have an atypical appearance and may be mistaken for other infections such as staph. Distribution typically more diffuse than typical HSV infections. Occurs on body surfaces areas that typically come into contract with opponents (face, head, neck, ears, upper extremities). Lesion location typically on side of patient’s handedness. Recurrences occur at location of initial outbreak, a useful diagnostic aid.
Perform a thorough examination as ocular involvement was seen in 8% of high school wrestlers in one HG outbreak.
Typical treatment for primary infection is Valacyclovir 1g PO b.i.d. for 7 days. This is best started within 24h of symptom onset.
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The clinical examination is often unreliable in ruling out septic arthritis in the ED.
Diagnostic arthrocentesis is often performed.
Traditional teaching involved very high WBC count thresholds as part of diagnosis.
In one 2009 study, synovial leukocyte counts in cases of MRSA were often less than 25,000 cells/uL
Have a low threshold for empiric antibioitics even in the face of low WBC counts (and incredulous consultants)
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Overtraining syndrome
A maladaptive response to excessive exercise without adequate functional rest
-Results in disturbances of multiple body systems (neurologic, endocrinologic, immunologic and psychologic).
- May be caused by systemic inflammation and resultant neurohormonal changes
- Multiple hypotheses exist
-Symptoms
Parasympathetic alterations: fatigue, depression, bradycardia
Sympathetic alterations: insomnia, irritability, agitation, tachycardia, hypertension, restlessness
Other: anorexia, weight loss, poor concentration, anxiety
Usual presentation is prolonged underperformance despite adequate rest and recovery (weeks to months).
Pelllegrini-Stieda lesion
Ossified post-traumatic lesions at the MCL adjacent to the femoral attachment site of the medial femoral condyle.
Mechanism is likely from an avulsion injury that subsequently calcifies after the initial trauma.
Often an incidental finding on plain films.
If symptomatic, refer to ortho as an outpatient
If not symptomatic, no treatment is indicated
http://images.radiopaedia.org/images/30076/b62e61e83241e30f2da693901edcdc_gallery.jpg
http://www.imageinterpretation.co.uk/images/knee/PELLEGRINI%20STIEDA2.jpg
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No single feature of the history of physical examination reliably rules out ostemyelitis
Aids in making the diagnosis include:
An ulcer area larger than 2 cm2 (LR 7.2),
A positive probe to bone test (LR 6.4),
An ESR greater than 70 mm/h (LR 11)
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Treating knee osteoarthritis - from the American College of Rheumatology
Exercise whether it be aquatic, aerobic (land -based) or resistance can decrease pain and improve functional capacity. Exercise should be performed 3 to 5 times a week. Effects are usually noted after 3 to 6 months.
Weight loss of 5% or greater body weight is associated with a small improvement in pain and physical function. The main benefit of weight loss has more to do to effects on co-morbid conditions.
Walking aids: A single crutch or cane should be held on the side contralateral to the affected knee and should be advanced with the affected limb when walking to reduce the load on the affected joint.
Cane sizing: The distance from the floor to the patient's greater trochanter (brings the elbow to 15º to 20º of flexion.
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Unexplained respiratory symptoms during exercise are often incorrectly considered secondary to exercise induced asthma/bronchospasm.
An important diagnosis on the differential should be exercise-induced laryngeal obstruction (EILO).
Of 91 athletes referred for asthma workup, 35% had EILO.
The presence of inspiratory symptoms did not differentiate athletes with and without EILO.
61% of athletes with EILO used regular asthma medication at referral.
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Cauda equina syndrome results from compression of multiple lumbar and sacral nerve roots
Causes: Central disc herniation, spinal epidural abscess, malignancy, trauma, hematoma.
Consider this entity in those with back pain and radiculopathy at multiple spinal levels
Urinary retention occurs in >90% of patients
Saddle anesthesia occurs in 75%
Decreased rectal sphincter tone occurs in 60 to 80%
A post void residual volume <100 mL makes this entity very unlikely
Lateral hip pain
Findings of weakness and/or pain while testing hip abduction may point to gluteus medius muscle dysfunction with associated with greater trochanteric pain syndrome.
The Trendelenburg test may help. The patient stands on the affected leg. A negative test result occurs when the pelvis rises on the opposite side. A positive test result occurs when the pelvis on the opposite side drops and indicates a weak or painful gluteus medius muscle.
http://www.youtube.com/watch?v=TY-G4ErruUA