Keywords: Concussion, return to play, school, head injury (PubMed Search)
You have successfully diagnosed a concussion, explained everything to the parents, closed the encounter, reached for the doorknob and….
“What about school?”
An athlete should not return to play until they have successfully returned to school
Several studies have demonstrated that intense cognitive stimulation and intense intellectual stimulation result in worsening symptoms
-school work, TV, videogames, texting
Attempt to limit cognitive activity to the point where it begins to reproduce or worsen symptoms!
Step 1: 24 to 48 hours of rest
Step 2: Daily at home activities that do not increase symptoms. Starting with 5 – 10 minutes and gradually build up to a goal of tolerating 30 minutes of cognitive activity without worsening symptoms.
Home work, reading assignments, other cognitive activities
Step 3: Attempt Return to school (will not be completely symptoms free!) with either part time, partial days, or with extended breaks. Goal of tolerating an entire school day without symptoms.
Most students recover fully within 4 weeks and adjustments can then be discontinued. Others with ongoing symptoms may require ongoing academic modifications (extra time for tests, papers, etc).
Suggested examples of adjustments: Shortened days, 15 minute break for every 30 minutes of instruction, providing class notes, tutoring, decreasing course expectations, decreasing exposure to classes which exacerbate symptoms, no computer work, untimed tests and quizzes, lunch in a quiet place.
Bass & Valasek Auguest 2018 Contemporary Pediatrics
Keywords: thrower, insability (PubMed Search)
25yo baseball pitcher presents with medial elbow pain. He felt a painful “pop” and could not continue to throw (due to loss of speed and control). Mild paresethesias in 4th and 5th digits.
What physical examination maneuvers can you do at the bedside to assist in the diagnosis?
Exam opposite elbow first to establish baseline and to assist patient relaxation and understanding.
Flexing elbow to 20 to 30 degrees unlocks the olecranon
Keywords: Ulnar nerve (PubMed Search)
Tests for motor weakness of the Ulnar nerve
Patient asked to hold piece of paper in both hands, grasping with the thumb and radial side of index finger of both hands
Examiner then pulls on the paper
Test is positive if patient flexes the thumb IP join in an attempt to hold onto paper
Category: Airway Management
Keywords: foot, necrosis (PubMed Search)
Osteonecrosis of the tarsal navicular bone
Affects children ages 4 to 7
4x more likely in males
Can be painless or present with arch/midfoot pain and a limp (usually activity related)
Usually unilateral but can be bilateral (in up to 25%)
PE: Tenderness to palpation over the length of the arch esp the medial navicular
Swelling, warmth, redness
-Can be misdiagnosed as an infection
X-ray: Sclerosis, collapse/flattening or fragmentation of navicular
Treatment: Walking boot or short leg cast
Keywords: Heat illness (PubMed Search)
Exertional Heat Stroke (EHS)
With football preseason starting across the country, it is important to review this topic
EHS is a medical emergency resulting from progressive failure of normal thermoregulation
EHS has a high mortality
-2nd most common cause of death in football players
History and Exam
Hyperthermia/Core temperature greater than 40°C (104°F)
Initial profuse sweating with eventual cessation of sweating with hot, dry skin
CNS dysfunction – disorientation, confusion, dizziness, inappropriate behavior, difficulties maintaining balance, seizures, coma
Other: Tachycardia/hyperventilation, fatigue, vomiting, headache
Multi-organ involvement: CNS, cardiac damage, renal failure, hepatic necrosis, muscle (rhabdomyolysis), GI (ischemic colitis), heme (DIC), ARDS
The single most important thing you can do on the field is recognize this entity. Early recognition leads to earlier initiation of treatment which is life saving.
Rapid cooling is key. This is often stated but what this means is whole body immersion in ice water. This should be available and ready for all summer practices.
The temperature needs to be lowered to below 39°C (102°F)
Also consider a cooling blanket, fanning, ice to body
DO NOT put them on ambo without initiating cooling!!!
Sustaining heat injury predisposes to subsequent heat related injury
Keywords: Muscle pain, exercise (PubMed Search)
Delayed Onset Muscle Soreness (DOMS), aka “muscle fever”
Muscle pain and weakness following unfamiliar exercise
Occurs after high force, novel (unaccustomed) eccentric muscle contractions
Occasionally isometric in an extended position
Eccentric exercise – controlled elongation
Slowly lowering yourself to start position doing pullups for example
Time of onset
Begins 6 to 12 Hours after exercise, Peaks 2-3days post and resolves in 5-7 days
Speed of onset and severity are often related
How do you know if you have it?
Much like the flu, you know it when you have it. The simple act of getting out of a car, sitting down or walking down stairs is excruciatingly painful.
Exact cause is unknown. Thought to be due to sarcolemma damage leading to intra cellular calcium release and activation of proteolytic enzymes. Creatine kinase leaks from muscle cells into plasma attracting inflammatory cells.
Best treatment is prevention: Repeated bout effect – a bout of eccentric or isometric exercise can prevent DOMS from the same exercise for 4-12 weeks.
Stretching before exercise has not been shown to be effective prevention
Other modalities: rest, ice, heat, massage, electrical stimulation
Eccentric exercises or novel activities should be introduced progressively over a period of 1 or 2 weeks at the beginning of the sporting season or the start of a new, novel exercise routine. For example, not starting the Insanity day one workout without “pretraining.” This will reduce the level of physical impairment and/or training disruption and lead to gains with much less pain.
Keywords: Cervical spine, neuropraxia (PubMed Search)
Stingers and Burners
Also known as transient brachial plexus neuropraxia, “dead arm syndrome,” or brachial plexopathy. Symptoms such as pain, burning, and/or paresthesias in a single upper limb, lasting seconds to minutes.
Usually involves more than one dermatome
May be associated with weakness.
-Common in collision sports that involve tackling, such as football.
-Most common C-spine injury in American Football.
-More than 50% of college football players sustain a stinger each year
-Having 1 stinger increases the risk of having another 3 fold
Mechansims: C5, C6 (deltoid,biceps) most commonly involved
-Traction injury due to forcible lateral neck flexion away with downward displacement of arm
-Nerve root compression during combined neck extension and lateral neck flexion
-Direct trauma to the brachial plexus in the supraclavicular fossa
-Examine muscle strength in the deltoid, biceps, and infraspinatus muscles
-Check sensation and reflexes in upper extremities
-Check C-spine range of motion and perform Spurling’s Test
Consider MRI for symptoms lasting more than 24 hours, bilateral symptoms or for recurrent stingers
Return to play guidelines vary:
-No neurologic symptoms
-Can return to play in same game if symptoms resolve within 15 minutes and no prior stingers that season.
-If 2nd stinger in that season, do NOT return to play in the same game
-if 3rd stinger in a season, consider imaging before return to play and consider sitting out the remainder of the season.
ED visits for acute gout increased almost 27% between 2006 & 2014, a 26.8% increase
Presentation: Acute severe pain, swelling, redness, warmth.
Pain peaks between 12 to 24 hours and onset more likely at night
Quiet, calm period between flares vs other arthritic disorders
Signs of inflammation can extend beyond the joint
Normal to low serum urate values have been noted in 12 to 43% of patients with gout flares
Accurate time for assessment of serum urate is greater than 2 weeks after flare subsides
Most hyperuricemic individuals never experience a clinical event resulting from urate crystal deposition.
Gout flares may occasionally coexist with another type of joint disease (septic joint, psedugout),
A clinical decision rule has shown to be more accurate than clinical diagnosis (17 versus 36%)
*Male sex (2 points)
*Previous patient-reported arthritis flare (2 points)
*Onset within one day (0.5 points)
*Joint redness (1 point)
*First metatarsal phalangeal joint involvement (2.5 points)
*Hypertension or at least one cardiovascular disease (1.5 points)
*Serum urate level greater than 5.88 mg/dL (3.5 points)
Scoring for low (≤4 points), intermediate (>4 to <8 points), and high (≥8 points) probability of gout identified groups with a prevalence of gout of 2.2, 31.2, and 82.5 percent, respectively.
Consider supplementing your clinical decision with this in the future
Miathal A, Singh G. Emergency department visits for gout: a dramatic increase in the past decade. Oral presentation at the EULAR 2018 European Congress of Rheumatology in The Netherlands, June 13–16.
Kienhorst LB, et al. The validation of a diagnostic rule for gout without joint fluid analysis: a prospective study.Rheumatology (Oxford). 2015;54(4):609.
Becker, MA. Clinical manifestations and diagnosis of gout. Up to date. 2018
Syndesmotic sprain aka a “high ankle sprain”
Ankle injuries make up almost 30% of the injuries in professional football
High ankle injuries make up between 16 and 25% of these injuries in the NFL (lateral most common)
10% in general population
In comparison to lateral ankle sprains, high ankle sprains result in significantly more missed games, missed practices and required a longer duration of treatment
Anatomy: The syndesmosis comprises several ligaments and the interosseous membrane
Mechanism: External foot rotation with simultaneous rotation of the tibia and fibula.
Can lead to a Maisonneuve fracture
Injuries 4x more likely in game setting than practice
A positive proximal squeeze test significantly predicts missed games and practices compared to those without.
Conservative management for the stable high ankle injuries in professional football players. Knapik et al. Sports Health 2018
Keywords: Heat, exertion, muscle (PubMed Search)
Exertional rhabdomyolysis (ER)
The warm weather is here and with it comes an increased risk of ER
Risks include the intensity, duration and types of exercises performed
One of the biggest risks is the exercise experience of the participants, both in those with little to no experience and in those experienced athletes less trained than their counterparts.
Multiple case reports find that intense novel exercises early in the preseason before getting acclimatized and “in shape” carry great risk to the participant. These can be summarized as “too much, too soon, too fast.”
Coaches need to be educated about this and be prepared to detect and effectively handle ER through an emergency action plan.
-Conditioning workouts need to be phased in rather than start at maximum intensity on day one.
Eccentric exercises appear worse than concentric exercises.
Has been seen in almost all sports, ranging from swimming to golf.
It’s not just preseason football!
High humidity and high temperature environments increase the likelihood of ER
Males are more vulnerable to ER than females
Increased risk with sickle cell trait and glycogen storage diseases
Multiple drugs may increase individual risk including alcohol, cocaine, amphetamines, MDMA and caffeine.
Implicated medicines include, salicylates, neuroleptics, quinine, corticosteroids, statins, theophylline, cyclic antidepressants and SSRIs
Football Team Rhabdomyolysis: The Pain Beats the Gain and the Coach Is to Blame Eichner, E., Randy, Current Sports Medicine Reports: May 2018
Keywords: Mild traumatic brain injury, concussion (PubMed Search)
Does mild traumatic brain injury increase risk of dementia?
Background: Most studies of moderate to severe TBI have found an association with increased risk of dementia and earlier onset of Alzheimer’s. There is growing concern that repeated TBIs, even if more mild, can lead to neurodegenerative conditions such as chronic traumatic encephalopathy (CTE). However, the link between mild TBI and dementia risk has not fully been elucidated, especially in the case of mild TBI without loss of consciousness (LOC).
Recent Data: A recent JAMA study evaluated the association between TBI severity, LOC, and dementia diagnosis in 350,000 veterans between 2001-2013. After adjusting for demographics as well as medical and psych comorbidities, veterans with even mild TBI without LOC had more than a 2-fold increase in risk of dementia diagnosis than those with no TBI. The risk increased only slightly if there was LOC (from a hazard ratio of 2.4 to 2.5). Risk was >3-fold for those with moderate-severe TBI.
Take home: TBI of any severity, even without LOC, appears to be associated with long term neurodegenerative consequences. Avoidance of TBI is of the utmost importance, and if TBI occurs, close neurocognitive follow up should occur.
Barnes DE, et al. Association of Mild Traumatic Brain Injury With and Without Loss of Consciousness With Dementia in US Military Veterans. JAMA Neurol. Online May 7, 2018.
Keywords: Pregnancy, sports medicine (PubMed Search)
Exercise talking points for the pregnant patient
(from ACSM 2017 Consesnsus statement)
Exercise throughout pregnancy is generally safe but should be monitored
No evidence of higher rates of preterm or prolonged labor, or deliveries that require induction or episiotomy
No evidence of negative effect on APGAR scores
Avoidance of excessive weight gain, improved balance, and decreased back pain
Improved well-being, energy levels, and sleep patterns
Improved labor symptoms and facilitation of post-partum recovery
Lower risk of C-section
Reduced risk of having a large for gestational age (LGA) or small for gestational age (SGA) infant
Risks include environmental exposure, dehydration, hypoxia, and uterine trauma:
High impact or high-strain physical activity during the fetal implantation phase may lead to slightly higher risk of miscarriage
Sports with high risk of trauma last in pregnancy could result in placental abruption
Scuba diving is contraindicated because the fetus is not protected from decompression problems
Limit use of sauna or hot tub to fewer than ten minutes or omit altogether
Female athlete issues for the Team Physician: A consensus statement- 2017 Update
American College of Sports Medicine, 2018
Keywords: Stress fracture, amenorrhea (PubMed Search)
Energy availability considers the amount of remaining energy for metabolic processes based on calories takin in with eating and calories burned through exercise or both.
Menstrual dysfunction occurs as a result of low energy availability causing decreased GnRH inhibition and ovarian suppression and decreased estrogen.
Low bone mineral density occurs due to amenorrhea and decreased energy availability. Estrogen limits bone resorption (stimulates calcitonin and renal calcium retention).
This is very important for young girls as by age 12 they have 83% of their total BMD & 95% two years after menarche.
If you see an athlete in the ED with one component of the triad, inquire about the other two. A 15yo athlete with a stress fracture may not realize that her disordered eating, excessive exercise or amenorrhea may by contributing factors and may benefit from follow up with PCP, dietitian, Gyn, etc.
Keywords: Hand injury (PubMed Search)
aka buttonhole deformity
Misdiagnosed as a “jammed” or “sprained” finger
Keywords: Shoulder pain, muscle injury (PubMed Search)
Pectoralis Major Rupture
Most commonly seen in male weightlifters
Usually occurs as a tendon avulsion
Incidence is increasing
Hx: Sudden, sharp, tearing sensation with pain and weakness with arm movement
PE: Palpable defect and deformity of anterior axillary fold. Bruising and swelling.
Deformity may not be obvious with arm by side and relaxed
Testing: Weakness with ADDuction and internal rotation
Treatment: Operative treatment has better outcomes but depends on patient subgroups
Nonoperative treatment generally indicated for partial ruptures and tears in the body of the pec and muscle tendon junction
Sling, ice and pain control.
Operative treatment generally for high demand patients (athletes) and bony avulsion injuries
Keywords: Mild traumatic brain injury, concussion (PubMed Search)
The search for an objective reliable test for mild traumatic brain injury found an early promising result last week.
May be arriving in your hospital in the near future.
A handheld sideline version is sure to follow
The FDA approved the first blood test for concussion/mild TBI
Called the Banyan BTI (Brain Trauma Indicator)
This test measures 2 neural protein biomarkers released into the blood following mild TBI
The FDA approved this test within 6 months after reviewing data on just under 2,000 blood samples.
They concluded the Banyan BTI can predict the absence of cranial CT lesions with an accuracy greater than 99% and may reduce imaging in up to a 1/3rd
Be optimistic but consider the small sample size and remember that this test looks for biomarkers and may miss subtle cases where proteins didn’t leak. This test is NOT ready to be used for return to play decisions. It takes 3 to 4 hours to result and costs about $150. Other biomarkers are being investigated and may prove to be better
Keywords: Hip pain, athletes (PubMed Search)
Femoral neck stress fractures
Represents 5% of all stress fractures
Usually due to repetitive abductor muscle contraction
As with all stress fractures can occur in 2 types
1) Insufficiency type (normal physiologic stress on abnormal bone)
2) Fatigue type (abnormal/excessive physiologic stress on normal bone)
2 locations on interest:
1) Compression side (inferior femoral neck)
2) Tension side (superior femoral neck)
History: Insidious onset of groin or lateral hip pain associated with weight bearing
Exam: Antalgic gait, pain with hip log roll and with FABER (hip flexion, Abduction and external rotation test)
Compression side: reduced weight bearing and activity modification
Tension side: Non weight bearing (due to high risk of progression to displacement with limited weight bearing) AND surgical consultation for elective pinning to prevent displacement. If displaced, will require ORIF
Pevlis, hip and thigh injuries and conditions. Heidi Prather and Devyani Hunt. In Sports Medicine Study Guide and Review for Booards 2nd Edition. 2017
Keywords: Dental avulsion, tooth, trauma (PubMed Search)
Dental Avulsion in the field/sporting event
- Only replace avulsed secondary teeth
- Handle the tooth by the crown only
- Rinse tooth with cold running water gently (the root should not be wiped)
- Immediate attempt to reimplant permanent tooth into socket by 1st capable person:
* Time is tooth: Each minute tooth is out of socket reduces tooth viability by 1%
* Best chance of success if reimplant done within 5–15 min*? Poor tooth viability if avulsed for >1 hr
- If unsuccessful, place tooth in a transport solution (from most to least desirable):
- Hanks balanced salt solution (HBSS)
* Balanced pH culture media available commercially in the Save-A-Tooth kit
* Effective hours after avulsion
- Cold milk:
* Best alternative storage medium
* Place tooth in a container of milk that is then packed in ice (prevents dilution)
* Store in a container of parent or child's saliva
- Never use tap water or dry transport
Keywords: Head injury, concussion, sideline (PubMed Search)
Concussion – Where are we now?
The Sport Concussion Assessment Tool 5th edition (SCAT 5) was released in 2017
It is a standardized tool to assist health care professionals in the evaluation of sport associated concussions
It should be used for those 13 years and older (there is a child version for younger athletes)
Print and bring to the sideline for your next coverage event!
Some points to consider:
It should take at least 10 minutes to complete. Any less and you may not be performing the test correctly
The SCAT5 is the standard tool used in concussion assessment in the NCAA and NFL and other professional sports
Some symptoms of concussion appear over time. For example, an athlete may have zero or minimal symptoms immediately after yet be considerably symptomatic in 10 to 15 minutes.
-Follow up screening evaluations are essential even in those with a negative initial sideline screening test
The SCAT5 should be used immediately after injury
-Utility decreases post injury after days 3-5
-The included symptom checklist has utility in tracking recovery
-Attempt to perform in an environment free of distractions (crowd noise, bad weather)
The clinical utility of the SCAT5 can be enhanced by adding assessment of other factors such as reaction time, balance assessment, video-observable signs (if available) and oculomotor screening.
Keywords: 5th metatarsal, fracture, overuse (PubMed Search)
CC: 12yo boy presents with pain to base of 5th metatarsal
Osteochondrosis overuse syndromes associated with development of secondary ossification or apophyseal centers
Iselin disease – Osteochondrosis of 5th MT base
Lateral 5th foot pain with weight bearing and activity in early adolescence
Child may limp or walk on inner part of foot
Adolescents: Girls >10, Boys >12
Commonly seen in soccer, basketball, gymnastics and dance
Exam: Tenderness to palpation at proximal 5th MT at peroneal brevis insertion
Area may show edema and redness
Pain with foot inversion and resisted eversion and dorsiflexion
XR: May be normal or show enlargement or fragmentation of epiphysis
Obliquely oriented small bony fleck at 5th MT base. Parallel to long axis of 5th MT. Best seen on oblique view. Unlike fractures which tend to be horizontally oriented.
Treatment: Immobilize for comfort if severe (walking boot) or simple activity modification if mild. Ice and calf muscle stretching.