Ankle sprains are frequently lateral.
They occur less frequently to the medial or “high” ankle.
High ankle sprains without fracture occur in 5-6% of ankle injuries presenting to the ED
Rates of injury are much higher in college and professional hockey and football players
The tibiofibular syndesmosis is primarily injured in high ankle sprains
Mechanism: Typically, external rotation or eversion on a dorsiflexed ankle
Example: When a player’s leg is forcefully rotated while foot is planted
Hx: anterior lateral ankle pain. Frequently significant pain with weight bearing.
PE: local tenderness over the syndesmosis ligaments
Two specialized tests may aid in the diagnosis
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2. Dorsiflexion-external rotation test – This test attempts to reproduce the forces commonly involved in the original injury. Positive test is reproduction of pain. Position patient similar to above test. Grasp the upper calf with one hand while the other hand grasps the midfoot and places the foot in dorsiflexion and external rotation.
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Trigger finger/thumb
Occurs from mechanical impingement
-Stenosing tenosynovitis
Much more common in patients with diabetes
Causes clicking, catching, locking and pain
Occurs at the A1 pulley
Flexor tendon “catches” as it attempts to glide through a stenotic flexor tendon sheath
Initially, patient's report painless catching or locking of the affected digit during flexion
During finger flexion and extension, pain is caused by inflamed tendon passing through a relatively constricted tendon sheath
Occurs most often in the ring and middle digits
May improve over the course of the day
Diagnoses with active triggering (with digit flexion and extension) and tenderness to palpation at the first annular pulley (A1) which overlies the first MCP joint
-Ask patient to place hand on table face up and gradually fully flex and extend the fingers
May note a palpable nodule of the flexor tendon
Treatment: Activity modification, NSAIDs and splinting (3-6 weeks)
Corticosteroid injection is very effective
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Olecranon bursitis
Superficial synovial membrane located overlying the proximal ulna/olecranon allows for easy irritation and inflammation
Swelling does not involve the joint
Most common bursitis (approx. 4x more common than prepatellar)
Male>>Female
Prone to trauma, inflammation or infection
-RA, gout, overlying break in skin
Chronic inflammation results from excessive leaning on the elbow such as with certain occupations (plumber, military recruit)
Inflammation may be septic or aseptic
Usual cause is traumatic
Approximately 20% of acute cases may have a septic origin
Classically appears as a “goose egg” area on posterior elbow
Well-demarcated and fluctuant
Small amount of swelling and/or those with minimal symptoms should be left alone and treated with activity modification, NSAIDS, ice. Suggest an elbow pad for protection.
If this does not resolve symptoms after approximately 4 weeks, consider referral for aspiration and steroid injection
If aspiration is ED performed for evaluation of possible septic bursitis, recommend a compressive elbow sleeve to help prevent reaccumulating
If a recurrent issue for patient and aspirated, consider a posterior elbow splint for approx. 10 days and refer to orthopedics.
Shoulder Abduction Test aka Bakody’s Sign
Used clinically in the evaluation of patients with suspected cervical radiculopathy
Unlike Spurling’s test, where we create discomfort, this test attempts to relieve it.
Specifically, evaluates for nerve root compression at C4-C6/7
To perform:
Arm Abduction can be active or passive
3. Instruct the patient to hold this position for 30 seconds.
4.Observe the patient for any relief of symptoms (A positive test)
Decrease in pain, numbness, weakness or tingling
5. Repeat on the unaffected side for comparison.
Sensitivity: 17–78% Specificity: 75–92%
Note: when asked about what alleviates their pain, patients will frequently describe and demonstrate the maneuver.
Consider adding this simple maneuver in your assessment of patients with suspected symptomatic cervical radiculopathy
A northeast university was recently in the news when several members of the lacrosse team were hospitalized with rhabdomyolysis. 9 of 50 players who participated in the workout required hospitalization. This occurred after a single intense 45-minute workout led by an alum and recent graduate of the Navy Seal training program.
It was surprising to many that young, fit, athletes would be so affected from a single workout.
Nontraumatic exertional rhabdomyolysis occurs following intense physical activity especially in untrained individuals or those unaccustomed to the particular activity (for example a group of runners performing an intense HIIT workout).
Prolonged strenuous activity can result in rhabdomyolysis even in trained individuals in the absence of known risk factors or prior history.
Increased risk when natural cooling mechanisms are affected such as when the individual is taking medications with anticholinergic properties, or the individual is wearing heavy military gear or football equipment.
Increased risk with sickle cell trait.
Increased risk when that activity is performed in environments of severe heat and humidity.
Exercise routines that have a heavy eccentric focus increases risk of rhabdomyolysis.
An Eccentric exercise involves slow lengthening of muscles under load
Examples: the lowering phase of a barbell while performing a bench press or the downward phase of a pull up
Helpful kinetics:
Following the exertional event, the serum CK will rise within 2-12 hours, reaching its maximum in 1-3 days.
CK has a serum half-life of approximately 36 hours.
CK levels decrease at approximately 40% per day.
When it comes to walking, recent research and public health strategies have focused on how much you do that helps. This idea frequently comes up in the form of the 10,000 step goal.
A recent study in the British Journal of Sports Medicine found that walking between 9,000 and 10,000 steps/day could reduce the risk of death by 39% and cardiovascular disease by 21%.
For both outcomes (all-cause mortality and incident CVD), approximately 50% of the benefit was achieved between 4,000-4,500 steps per day.
Study accessed data on greater than 72,000 individuals (avg age 61, 58% female) using accelerometer data over an average of 6.9 years.
Instead of volume, a recent study in the same journal looked at the benefits of walking speed.
The study looked at pooled data from 10 studies involving more than 500,000 people from the U.S., Japan and the U.K.
Walking speed definitions:
Easy or casual walking - less than 2 mph.
Average or normal pace was defined as 2-3mph.
A “fairly brisk” pace was 3-4 mph
A “brisk/striding walking pace” was greater than 4mph
Compared with people who walked at a casual/easy speed, those who walked at a normal/avg speed (2–3 mph) had a 15% lower risk of Type 2 diabetes.
Walking at a fairly brisk pace (3–4 mph) was associated with a 24% lower risk of Type 2 diabetes.
Walking at a brisk or striding pace (over 4 mph) was associated with a 39% reduced risk of Type 2 diabetes.
Globally, 537 million adults have type 2 diabetes, a figure that is expected to reach 783 million by 2045.
Take home: Consider recommending tips on walking pace and distance for our sedentary patient population to optimize health.
The Lever test can be used to examine for a torn ACL
May be helpful when examining larger patients
Place patient supine with both knees extended. Examiner places fist below the proximal third of patient’s calf.
With the other hand, the examiner presses down on the distal third of the patient’s quadriceps.
Positive test: A torn ACL disrupts the lever arm of the lower leg. The heel will not rise.
Negative test: An intact ACL allows the lever arm of the lower leg to lift the heel. The heel will rise.
More study is needed but reported sensitivities are similar to classic tests such as the anterior drawer or Lachman.
What is the best provocative test for the diagnosis of carpal tunnel syndrome?
A 2022 study included 37 observational studies to assess the diagnostic accuracy of these provocative maneuvers.
Meta-analysis totaling 2662 wrists of patients with carpal tunnel syndrome.
Surprisingly, the winner was a test that is less familiar to some of us who were taught the traditional tests such as the Phalen test, Tinel test or the carpal tunnel compression test.
Hand elevation has been known to reproduce the symptoms of carpal tunnel syndrome.
The hand elevation test demonstrated the best clinical performance for the diagnosis of carpal tunnel syndrome.
The beauty of the test is that it is as simple to perform as the name suggests.
Have the patient raise their hands above their head for one minute.
Hands are raised actively and without strain, keeping the elbows and shoulders relatively loose. That’s it!
A positive test reproduces the symptoms of carpal tunnel syndrome
The hand elevation test has a high sensitivity (75%-86%) and specificity (89%-98.5%)
Take home: Consider adding this bedside provocative test as the first screening test for patients with suspected carpal tunnel syndrome
A 2020 meta-analysis attempted to estimate the frequency of radiographically occult hip fractures in the elderly population.
26 studies evaluated the rate of surgical hip fractures with no obvious findings on plain film.
Median age 80.3 years (67-82 years).
MRI used as gold standard.
The overall rate of radiographically occult hip fracture requiring surgery was 39%.
This percentage is higher than reported in other studies which may have included non-elderly patients, retrospective bias or other issues.
Overall, 18% had femoral neck fractures, 17% had intertrochanteric fractures and 1% had subtrochanteric fractures.
Elderly patients with acute hip pain and negative or equivocal findings with initial plain film imaging have a high frequency of occult hip fractures. Strongly consider advanced imaging in this population
Hip Fractures
Femoral neck and intertrochanteric fractures occur most commonly among patients aged 65 and over
Major risk factors for hip fractures include osteoporosis and falls.
Patients with a low body mass index (BMI <22) appear to be at higher risk
Isolated trochanteric fractures occur more often in young active adults
In-hospital mortality rates are approximately 5% (range 1-10%)
In addition to making the diagnosis and consulting orthopedic surgery, ED providers must remember to provide adequate analgesia as elderly patients are often under medicated.
-Up to 72% receive no prehospital analgesia.
Extracapsular fractures cause more pain than intracapsular fractures due to the greater degree of periosteal trauma.
Poor pain control predisposes hip fracture patients to delirium
Retrospective studies indicate that patients at higher risk for significant bleeding have at least 2 of the following risk factors:
Age over 75 years, initial Hgb below 12 g/dL and peri trochanteric fracture location.
A recent study attempted to investigate the relationship between a history of strength training with symptomatic and structural findings of knee osteoarthritis (OA).
For comparison, previous studies have shown that duration of football participation increases risk of radiographic knee OA.
Methods: Retrospective, cross-sectional multicenter study
2,607 participants without OA. Community population. 44% male. Mean age 64.3 years. Mean BMI 28.5.
Strength training (via self-administered questionnaire) defined as those exposed (n=1789 ) and not exposed (n=818). If exposed, groups were divided into low, medium and high.
Outcomes were 1) Radiographic OA. 2) Symptomatic radiographic OA. 3) Frequent knee pain
Results: Strength training at any point in life vs no strength training was associated with lower incidence of all outcome measures:
Odds ratio1) 0.82, 2) 0.83 and 3) 0.77.
Conclusions: Strength training is beneficial for future knee health
However, when separated by groups (low, medium and high), only the high-exposure group had significantly reduced odds of less frequent radiographic OA, symptomatic radiographic OA, and frequent knee pain.
Findings were similar for different age ranges
The association between strength training and less frequent radiographic OA, symptomatic radiographic OA, and frequent knee pain was strongest in the older age groups.
A recent study in Annals of EM investigated the use of topical Diclofenac in the treatment of lower back pain.
Small studies have shown topical NSAIDs to be effective for single joint OA and tendinopathies.
Currently, NSAIDs are first-line treatment for ED patients with acute low back pain.
Theoretically, topical NSAIDs deliver medications directly to the injured tissue while minimizing systemic side effects.
-Topical NSAIDs provide similar concentrations of the drugs in muscle tissue but much lower plasma concentrations than oral formulations
Design: Randomized, double-blind, placebo-controlled trial.
ED patients aged 18 to 69 years with non-radicular, non-traumatic acute lower back pain.
Screened 3,281 and enrolled 198.
Study groups:
Patients received 2 days of meds. Follow up by phone at 2 and 7 days.
Investigators used the RMDQ score to measures pain and functional impairment.
Results: At the 2 day follow-up, all 3 groups showed an improvement in the mean RMDQ score compared to baseline as expected.
Participants had a mean RMDQ improvement of 10.1 in the ibuprofen group, 6.4 in the diclofenac gel group, and 8.7 in the ibuprofen + diclofenac gel group.
At the 7-day follow-up, participants had a mean RMDQ change compared to baseline of 12.2 in the ibuprofen group, 9.5 in the diclofenac group, and 10.7 in the ibuprofen + diclofenac gel group.
Conclusion: This study does not support the use of topical diclofenac among patients who can otherwise tolerate oral ibuprofen.
Because the study did not compare placebo gel to topical Diclofenac, we cannot infer whether topical medication is helpful for treatment in acute lower back pain in those patients who may not be able to take NSAIDs.
Concussion Visits to the Emergency Department
In a study looking at concussion discharge instructions in the ED:
A 2020 study looked at patients aged 6-18 years diagnosed with concussion on either first or subsequent ED visit.
Those patients with delayed diagnosis required more medical visits during recovery, had a significantly longer time to symptom resolution (21 vs. 11 days), and had a higher likelihood of having persistent concussion symptoms.
Take home: Consider printed concussion discharge instructions in the appropriate ED patients as this has downstream benefits for health and recovery.
New progress in head injury prevention in football
A Guardian Cap is a soft padded soft shell worn over football helmets.
Think of it like a shock absorber
It is intended to mitigate energy transfer to the head and neck during player impacts.
It retails for about $70 on amazon!
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Most NFL players have worn these caps during preseason practices for the past 2 years.
The NFL found a 52% reduction in preseason concussions (at the same position) between players who wore the cap versus those who did not.
In laboratory testing the Guardian cap reduced head impact forces by up to 1/3rd in certain impacts.
Per NFL analytics, the Guardian cap absorbs 10% of the traumatic force.
Additionally, if two players suffer a helmet to helmet hit in which each wears the cap, the impact force is reduced by 20%!
The NFL has allowed players to wear the caps this year
They will have the team logos on them
2024 season: Players will wear the caps or one of 6 approved helmets (position specific) that provide equal or better protection.
If your child plays football, consider investing in this product as a potential means to reduce head impact forces and concussion.
More data is needed during regular season games with full speed collisions.
Metacarpal fractures are frequently seen in the ED.
These are frequently non operative injuries.
For 4th and 5th metacarpal fractures, consider an ulnar gutter spilt.
For 2nd and 3rd metacarpal fractures, consider a radial gutter splint.
Splinting position (Intrinsic plus):
Wrist in approximately 20 degrees of extension (position of function)
MCP joint in 70 to 90 degrees of flexion
Slight flexion at the DIP and PIP and DIP joints.
-Important to prevent shortening of the collateral ligaments
The OPAL trial attempted to investigate the effectiveness of opioids in the acute management of neck and back pain.
346 adults presenting to the Emergency department or primary care provider with 12 weeks or less of lower back pain, neck pain or both (of at least moderate intensity).
51% male. 49% female.
Location: Sydney, Australia
All participants received guideline care (advice to stay active, reassurance of a positive prognosis, avoidance of bed rest, and, if required, other non-opioid analgesics).
Patients were then randomly assigned to an opioid (oxycodone, up to 20 mg PO qD) or and an identical placebo, for up to 6 weeks*.
*Trial used a combination oxycodone/naloxone to reduce risk of opioid induced constipation and assist with blinding.
*Trial used a modified release formulation that could be dosed q12h rather than q4-6h to increase adherence.
*Recommended regimen was oxycodone 5mg every 12 hours, with titration as necessary, max dose 20mg total per day.
*Trial physicians were able to individualize the prescription to suit the patient’s needs.
* Mean prescribed dose was approx. oxycodone 10mg total daily.
*Most patients only treated for 2 weeks
Primary outcome: Pain severity at 6 weeks
Results: Mean pain score at 6 weeks was identical between groups.
Trend towards faster recovery in the placebo group in the first 2 weeks.
Take home: Consider the likely benefit vs harm of prescribing opioids for acute back and neck pain in the ED.
Acetaminophen and low back pain.
Acetaminophen has been a traditionally recommended first line intervention for acute low back pain.
Cochrane reviews in 2016 and 2023 found that acetaminophen showed no benefit compared to placebo in patients with acute low back pain.
A 2020 study investigated whether the addition of acetaminophen to short term NSAID therapy was beneficial.
A randomized double-blind study conducted in two urban emergency departments.
Patients randomized to a 1-week course of ibuprofen plus acetaminophen versus ibuprofen plus placebo.
Population: patients presenting with acute, non-radicular, non-traumatic lower back pain of fewer than two weeks duration.
Authors compared pain and functional outcomes at one week following discharge.
Conclusion: there was no outcome benefit from the addition of acetaminophen to ibuprofen.
Axial neck pain is a dull aching “soreness” pain from the posterior neck muscles with radiation to the occiput, periscapular and shoulder regions.
Associated with headaches, stiffness and muscle spasm.
Patients with cervical radiculopathy, however, usually present with unilateral pain discomfort.
Patients may complain of pain radiation into the ipsilateral arm. Though frequently difficult to describe, this may be in a dermatomal distribution. Patients may also report decreased sensation in a dermatomal distribution or weakness along the corresponding myotome.
The most affected nerve roots are C7 (C6-7 herniation), followed by C6 (C5-6 herniation) and C8 (C7-T1 herniation).
Cervical Spondylosis (degenerative change) is the most common ideology.
As discs breakdown with age and lose height, increased force loads are transmitted to bony regions of the spinal segment leading to bone hypertrophy which creates foraminal stenosis and resultant radiculopathy.
Cervical radiculopathy, like lumbar radiculopathy, is largely a self-limited condition. Several older studies following this diagnosis revealed that a majority of patients were either asymptomatic or mildly symptomatic at time of follow-up.
Improvement is seen over the initial four to six months following diagnosis.
Reducing musculoskeletal injury and concussion risk in schoolboy rugby players with a pre-activity movement control exercise programme: a cluster randomised controlled trial
Intro: Musculoskeletal injuries and concussion are prominent reasons for time loss from sport for adolescent rugby players.
Injury patterns in rugby differ from other team sports,
-Greater frequency of concussion, upper body and contact-related injuries
Increased concussion risk is associated with lower neck strength, highlighting this characteristic as a potentially modifiable risk factor.
Enhancing neck muscle strength may prevent concussion by improving the dissipation of impact forces transmitted to the brain.
The aim of study was to determine the efficacy of a movement control exercise program in reducing injuries in youth rugby players.
Methods: In a cluster-randomized controlled trial, 40 independent schools (118 teams, 3188 players aged 14-18 years) were allocated to receive either the intervention or a reference program, both of which were to be delivered by school coaches.
The intervention comprised balance training, whole-body resistance training, plyometric training, and controlled rehearsal of landing and cutting maneuvers. This also included a neck strengthening component.
Time-loss (>24 hours) injuries arising from school rugby matches were recorded by coaches and medical staff.
Results: When trial arm comparisons were limited to teams who had completed three or more weekly program sessions on average, clear reductions in overall match injury incidence (RR=0.28) and concussion incidence (RR=0.41) were noted in the intervention group.
Conclusion:
