UMEM Educational Pearls - Orthopedics

Hand elevation test

 

  • Hand elevation has been known to reproduce the symptoms of carpal tunnel syndrome.

 

  • This phenomenon prompted the idea of developing a simple hand elevation test to diagnose carpal tunnel syndrome. 

 

  • To perform: Ask the patient to elevate both arms in the air for one minute. Hands are raised actively and without strain, keeping the elbows and shoulders relatively loose.

 

  • A positive test reproduces symptoms of carpal tunnel syndrome. 

 

  • The hand elevation test has a high sensitivity (75-86%) and specificity (89-98.5%) and may be comparable to or likely better than other provocative tests.

 

https://www.youtube.com/watch?v=IO2qC5qHVFE

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Category: Orthopedics

Title: ESR and CRP in Spinal Infection

Keywords: Epidural abscess, back pain, vertebral osteomyelitis (PubMed Search)

Posted: 5/8/2021 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Both erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are highly sensitive (84-100%) for spinal infections and are observed in >80% with vertebral osteomyelitis and epidural abscesses.

 


ESR 

Most sensitive and specific serum marker, usually elevated in both spinal epidural abscess (SEA) and vertebral osteomyelitis.  

ESR was elevated in 94-100% of patients with SEA vs. only 33% of non-SEA patients

Mean ESR in patients with SEA was significantly elevated (51-77mm/hour)

CRP 

Not highly specific

Less useful for acute diagnosis since CRP levels rise faster and return to baseline faster than ESR (elevated CRP seen in 87% of patients with SEA as well as in 50% of patients with spine pain not due to a SEA)

Better used as a marker of response to treatment.  

 

 

 

 

 

 

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Erythrocyte sedimentation rate (ESR) for spinal infection

 

Sensitive for spinal infection but not specific

Elevated ESR is observed in greater than 80% of patients with vertebral osteomyelitis and epidural abscess

ESR is the most sensitive and specific serum marker for spinal infection

               Usually elevated in acute presentations of SEA and vertebral osteomyelitis

ESR was elevated in 94-100% of patients with SEA vs. only 33% of non-SEA patients

Mean ESR in patients with SEA was significantly elevated (51-77mm/hour)

Infection is unlikely in patients with an ESR less than 20 mm/h.

Incorporating ESR into an ED decision guideline may improve diagnostic delays and help distinguish patients in whom MRI may be performed on a non-emergent basis

 

 

 

 

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Category: Orthopedics

Title: Emergency department patients with mTBI prescribed light exercise

Keywords: Concussion, mTBI, exercise prescription (PubMed Search)

Posted: 4/10/2021 by Brian Corwell, MD (Updated: 8/17/2022)
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Study Question:  A recent study investigated whether adult patients presenting to the ED with a diagnosis of mTBI prescribed light exercise were less likely to develop persistent postconcussion symptoms.

Setting:  Randomized controlled trial conducted in three Canadian EDs. Consecutive, adults (18–64 years) seen in ED with a mTBI sustained within the preceding 48 hours.

The intervention group received discharge instructions prescribing 30 minutes of daily light exercise.

The control group was given standard mTBI instructions advising gradual return to exercise following symptom resolution.

Outcome:  The primary outcome was the proportion of patients with postconcussion symptoms at 30 days,

A total of 367 patients were enrolled. Median age was 32 years Male 43%/Female 57%.

Result:  There was no difference in the proportion of patients with postconcussion symptoms at 30 days. There were no differences in median change of concussion testing scores, median number of return PCP visits, median number of missed school or work days, or unplanned return ED visits within 30 days. Participants in the control group reported fewer minutes of light exercise at 7 days (30 vs 35).

Conclusion

Prescribing light exercise for acute mTBI, demonstrated no differences in recovery or health care utilization outcomes.

Extrapolating from studies in the athletic population, there may be a patient benefit for light exercise prescription.

Make sure that the patient is only exercising to their symptomatic threshold as we recommend with concussed athletes. Previous studies have shown that athletes with the highest post injury activity levels had poorer visual memory and reaction time scores than those with moderate activity levels.

 

 

 

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Category: Orthopedics

Title: Patellofemoral Syndrome

Keywords: patellofemoral, knee, pain (PubMed Search)

Posted: 3/13/2021 by Michael Bond, MD (Updated: 8/17/2022)
Click here to contact Michael Bond, MD

Bottom Line: In a recent meta-analysis the risk factors for patellofemoral syndrome are weak hip abduction strength, quadricep weakness in military recruits, and increased hip strength in adolescence.

PatelloFemoral Syndrome: Patellofemoral pain is not clearly understood and is believed to be multi-factorial.  Numerous factors have been proposed including muscle weakness, damage to cartilage, patella maltracking, as well as others.  Patient often complain of anterior knee that is aggravated by walking up and down stairs or squatting. Patellofemoral pain is extremely common. In the general population the annual prevalence for patellofemoral pain is approximately 22.7%, and in adolescents it is 28.9%.

Though commonly taught, the following have no evidence to support that they are a risk factor for patellofemoral syndrome: Age, Height, Weight, BMI, Body Fat or Q Angle of patella

 
 

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Home management versus PCP follow-up of patients with distal radius buckle (torus) fractures

 

A recent study investigated outcomes of patients with distal radius buckle fractures who were randomized to

 

  1. Home removal of splint and physician follow-up as needed (home management)  

 

Versus

 

  1. Prescribed PCP follow-up in 1-2 weeks


 

Noninferior study

 

Torus/buckle fractures of the distal radius are the most common fractures in childhood occurring on average in 1 in 25 children

 

This is a stable fracture typically treated with removable wrist splint and very rarely require orthopedic intervention

 

Outcome: functional recovery at 3 weeks

 

Randomized controlled trial at a tertiary care children’s hospital

 

All radiographs reviewed by pediatric radiologist with MSK specialization

 

149 patients. Mean age 9.5 years. 54.4% male

 

Telephone follow-up at 3 and 6 weeks following ED discharge by blinded interviewer

 

Primary outcome was comparison of Activities Scale for Kids-performance scores between groups at 3 weeks

 

Outcomes:  Home management performance score was 95.4% and PCP follow-up group was 95.9%. Mean cost savings were $100.10.

 

Conclusion:  Home management is at least as good as PCP follow-up with respect to functional recovery in ED patients with distal radius buckle fractures.

 

 

 

 

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Category: Orthopedics

Title: What time of day is best for exercise to achieve weight loss goals?

Keywords: diabetes, exercise, weight loss (PubMed Search)

Posted: 2/13/2021 by Brian Corwell, MD (Updated: 8/17/2022)
Click here to contact Brian Corwell, MD

What time of day is best for exercise to achieve weight loss goals?

 

Working out in the morning has traditionally held the edge, especially if done on an empty stomach.

Upon walking, elevated levels of cortisol and GH will aid in fat metabolism.

Switching to a morning workout may also decrease appetite throughout the day.

Morning exercise may also induce significant circadian phase?shifting effects. Patients report feeling more alert in the morning and get more tired at night. This may “force” people to get increased rest as poor sleep quality and duration has been associated with weight gain. 

Moderate intensity aerobic exercise has been shown to cause immediate mood improvement and mental productivity. These effects can last up to 12 hours and may be a simple aid to combat job stress.

However, a recent small study looked at this question with a group of men at high risk for Type 2 diabetes.

Those that exercised in the morning had better blood sugar control and lost more abdominal fat than those who exercised in the morning.

Study:  32 adult males (58 ± 7 years) at risk for or diagnosed with type 2 diabetes performed 12 weeks of supervised exercise training either:

In the morning (8.00–10.00 a.m., N = 12) OR

In the afternoon (3.00–6.00 p.m., N = 20)

Test: Graded cycling test with ECG monitoring until exhaustion

Results:  Compared to those who trained in the morning, participants who trained in the afternoon experienced superior beneficial effects of exercise training on peripheral insulin sensitivity, insulin?mediated suppression of adipose tissue lipolysis, fasting plasma glucose levels, exercise performance and fat mass.

Conclusion:  Metabolically compromised patients may benefit from shifting their exercise routine to the afternoon from the morning. Ultimately, any exercise is great in this population, but this study may be worth sharing to your patients.

 

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A recent retrospective observational study looked at the association of oral antibiotics (primarily fluroquinolones) and tendon rupture.

Outcome data is very interesting for our practice, deviates from traditional teaching.

Population:  1 million Medicare fee for service beneficiaries from 2007-2016 (>65 years old)

Antibiotics queried:  Seven total oral antibiotics of mixed class:

  1. Fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin)
  2. Other:  Amoxicillin, amoxicillin-clavulanate, azithromycin and cephalexin.

 

Outcome measures:  all combined tendon ruptures and 3 by anatomic site (Achilles, rotator cuff {RC} and other)

Results:  Of the 3 quinolones, only LEVOfloxacin showed a significant increase in risk of tendon rupture (16% for RC) and (120% for Achilles) in a 1 month window. The others did not show an increased risk

Among the other antibiotics, cephalexin showed an increase risk across all anatomic sites.

The authors note that the risk with levofloxacin never exceeded the risk of cephalexin in any comparison!

 

 

 

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Category: Orthopedics

Title: Chief complaint: "My hip snaps when I exercise"

Keywords: Hip pain, snapping hip, tendon (PubMed Search)

Posted: 12/27/2020 by Brian Corwell, MD (Updated: 8/17/2022)
Click here to contact Brian Corwell, MD

Chief complaint:  “My hip snaps when I exercise”

Both athletes and non-athletes may report a “snapping” sound with certain movements

This may affect up to 10% of the population

May be associated with activities than involve repetitive hip flexion

Symptoms may be due to an internal or an external cause

External causes are usually due to a tendon passing over a bony prominence

This can be felt as either an audible sensation and/or even a palpable snap

This may or may not involve pain or discomfort

This is most commonly due to a benign cause

During movements in flexion, extension or combined with internal rotation the iliotibial band may move over the greater trochanter.

Alternatively, the hamstring tendon may pass over the ischial tuberosity

There are several other causes with similar mechanisms

Symptoms are usually minimal and not serious

This can be reproduced on bedside clinical exam

               Ask the patient to identify the area of snapping with one finger which will help with anatomic localization

First line therapy is physical therapy which focuses on:

Improving muscle length if muscle is too tight   OR

Improving neuromuscular activation if problem is due to excessive muscle activation

 

 

 

 

 


Category: Orthopedics

Title: Postural Testing in Concussion

Keywords: Balance, mBESS, concussion (PubMed Search)

Posted: 12/12/2020 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

The Romberg test is part of the standard neurologic examination. The patient is asked to stand with feet together, hand on hips/sides and the eyes are closed. Vestibular and proprioceptive input is being tested. 

This test is not very sensitive overall, but especially in concussed athletes.

Many concussed athletes are able to stand relatively stable despite their neurologic injury.

In order to better identify postural instability in concussion, we perform 3 separate balance tests (modified balance error scoring system, mBESS).

A) Romberg

B) Single leg stance

  1. Standing on the non dominant foot, the hip is flexed to approximately 30° and the is knee flexed to approximately 45°.
  2. NonDominant Leg: The nondominant leg is defined as the opposite leg of the preferred kicking leg

C) Tandem Stance

https://www.researchgate.net/profile/Boaz_Saffer/publication/309591285/figure/fig2/AS:669641529626644@1536666390860/Balance-Error-Scoring-System-BESS-performed-on-firm-surface-A-C_W640.jpg

 

Have patient stand quietly with hands on hips

Have patient close eyes and start 20 second trial

If error occurs tell patient to return to start as quickly as possible

Examples of errors: opening eyes, lifting hands, falling out of position

 

 

 

 


Category: Orthopedics

Title: Anterior shoulder pain

Keywords: Shoulder, biceps, tendon (PubMed Search)

Posted: 11/28/2020 by Brian Corwell, MD (Updated: 8/17/2022)
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A 25 year old athlete presents to the ED with right anterior shoulder pain.

Pain radiates into proximal biceps.

It is worse with heavy lifting and especially “pulling” exercises at the gym.

 

How do we evaluate for biceps tendonitis?

  1. Tenderness to palpation in the bicipital groove
  2. Speed’s test
  3. Yergason’s test

 

Pathology is often the long head of the biceps

https://physioworks.com.au/wp-content/uploads/2019/12/biceps-tendonitis.jpg

Start by palpating this area and attempt to reproduce the discomfort

Speed’s test

 

Yergason’s test

  • Arm is placed to patient’s side, in pronation and flexed to 90 degrees at elbow
  • Patient attempts to supinate and externally rotate arm against resistance
  • https://youtu.be/rQ2Mp6aSi88

 

 


Category: Orthopedics

Title: Ulnar Collateral ligament injuries of the elbow

Keywords: Elbow, dislocation, instability (PubMed Search)

Posted: 10/25/2020 by Brian Corwell, MD (Updated: 8/17/2022)
Click here to contact Brian Corwell, MD

Ulnar Collateral ligament injuries of the elbow

 

Overhead throwing athletes are at risk of insufficiency and rupture of the ulnar collateral ligament (UCL) of the elbow

This can lead to valgus instability similar to what can occur in the knee

Overhead throwing places a significant valgus stress on the elbow

Though classically seen in baseball pitchers, may also be seen in javelin throwers and other high velocity throwing sports

In the acute setting may be seen after an elbow dislocation

History includes a “pop” and medial elbow pain following throwing activities

In cases of overuse injury, athletes will report a progressive loss of velocity, accuracy, and/or endurance with throwing.

The ulnar collateral ligament is the primary restraint to valgus stress from 30 to 120 degrees of flexion

One classic test for UCL instability is the milking maneuver

Patient may be sitting or standing

Patient’s forearm is supinated and elbow flexed at 90 degrees

A valgus force is applied by pulling the patient’s thumb while the examiner’s other hand stabilizes the elbow and palpates the medial joint line. 

Instability, pain or apprehension at the UCL is considered a positive test

https://www.youtube.com/watch?v=gbn24X_qqn0


Category: Orthopedics

Title: Carpal Tunnel Syndrome

Keywords: Carpal Tunnel Syndrome, neuropathy (PubMed Search)

Posted: 10/10/2020 by Brian Corwell, MD (Updated: 8/17/2022)
Click here to contact Brian Corwell, MD

Carpal Tunnel Syndrome (CTS)

 

The hallmark of classic CTS:  pain or paresthesia (numbness and tingling) in a distribution that includes the median nerve territory, with involvement of the first three digits and the radial half of the fourth digit.

The symptoms of CTS are typically worse at night and often awaken patients from sleep.

Fixed sensory loss is usually a late finding

Involves the median-innervated fingers BUT spares the thenar eminence.

This pattern occurs because the palmar sensory cutaneous nerve arises proximal to the wrist and passes over, rather than through, the carpal tunnel.

Consider a more proximal lesion in cases involving sensory loss in the thenar eminence

            Example: pronator syndrome

 

 


Category: Orthopedics

Title: Physical injury patterns associated with physical elder abuse

Keywords: Elder abuse, bruising, trauma (PubMed Search)

Posted: 9/26/2020 by Brian Corwell, MD (Updated: 8/17/2022)
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Physical injury patterns associated with physical elder abuse

 

Elder abuse is both common and underrecognized

Between 5 and 10% of US older adults are victims of elder abuse annually

For many older adults, contact with a health care provider may represent their only contact outside the home

Differentiating physical elder abuse from unintentional trauma can be very difficult

A recent study compared these two groups with a case-control design

Study cases: 100 successfully prosecuted physical elder abuse cases from a single urban ED

Physical abuse victims were more likely to have:

               Bruising (78% vs. 54%)

               Injuries to maxillofacial, dental or neck region (67% vs. 28%)

                              Particularly the LEFT side

                              Neck injuries 6x more common is assault

                              Ear injuries occurred in assault but not in falls

               Absence of fracture (8% vs. 22%)

               Less likely to have lower extremity injuries (9% vs. 41%)

22% of victims had no visible injuries

Most common mechanism assault with hands or fists and pushing or shoving causing a fall

Take home: Consider elder abuse especially in cases of the above red flags

              

              

 

 

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Category: Orthopedics

Title: Thoracic Spine Fractures in the Panscan Era

Keywords: Spine fracture, decision rule (PubMed Search)

Posted: 9/12/2020 by Brian Corwell, MD (Updated: 8/17/2022)
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A recent study looked at thoracic spinal fractures in the era of the trauma panscan

NEXUS Chest CT Study from 2011 to 2014 at 9 Level I trauma centers.

Goal: To describe the identification rate and types of thoracic spine fractures.

Inclusion: age over 14 years, blunt trauma occurring within 6 hours of ED presentation, and chest CT imaging during ED evaluation.

11,477 subjects, 217 (1.9%) had a thoracic spine fracture

The majority of spine fractures in patients who had both chest x-ray and CT were observed on CT only (91%). 50% had more than 1 thoracic spinal level involved (mean 2.1). 22% had associated cervical fractures and 25% had associated lumbar fractures.

               64% had vertebral body fractures

               45% had posterior column fractures

               28% had compression fractures

               6% had burst fractures

Many patients (62%) had associated thoracic injuries such as

               Rib fractures (45%)

               PTX (36%)

               Clavicle fracture (18%)

               Scapular fracture (17%)

               Hemothorax (15%)

 

100 patients had clinically significant thoracic spine fractures.

 

Thoracic spine fractures are relatively uncommon in adult patients with blunt trauma.

If thoracic spine fracture is suspected clinically, radiography is not an effective screen and clinician should consider CT. If not suspected, guidelines discourage ordering CT to screen for this injury because of effective screening instruments, the diagnosis of clinically insignificant injuries and radiation exposure.

All clinically significant thoracic spine fractures would have been detected by the NEXUS Chest CT decision instrument.

 

https://www.mdcalc.com/nexus-chest-ct-decision-instrument-ct-imaging

 

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Category: Orthopedics

Title: Diagnostic performance of Ultrasound for detection of pediatric elbow fractures

Keywords: Elbow, fracture, ultrasound (PubMed Search)

Posted: 8/12/2020 by Brian Corwell, MD (Emailed: 8/22/2020) (Updated: 8/17/2022)
Click here to contact Brian Corwell, MD

Diagnostic performance of Ultrasonography for detection of pediatric elbow fracture

Elbow fractures account for approximately 15% of pediatric fractures

Fat pads are traditionally taught as a marker of fracture

In a cadaveric study:

Elbow effusions of 1-3 mL could be identified with ultrasound

Elbow effusions of 5-10 mL could be identified with plain film

Pediatric plain films are sometimes challenging to obtain and interpret compared to adults

              -More likely to be uncooperative in obtaining required views

              -Non-ossified epiphyses

Ultrasound may be used to detect

              -Cortical disruption and irregularity

              -Growth plate widening

              -Hematoma interposed between fracture fragments

              -Elevated posterior fat pad

Absence of elbow fracture was indicated by

              -Lack of cortical disruption

              -Absence of posterior fat pad sign

Meta-analysis of 10 articles totaling 519 patients using ultrasonography to detect elbow fractures

              Sensitivity 96%

              Specificity 89%

              False negative rate 3.7%             

For comparison, plain radiographs

Interpreted by peds EM physicians (87.5% sensitive and 100% specific)

Interpreted by radiology (96% sensitive, 100% specific)

 

Consider using ultrasound as a noninvasive, radiation-free modality for accurate diagnosis of pediatric elbow fractures.

 

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Category: Orthopedics

Title: Pronator Teres Syndrome

Keywords: Peripheral neuropathy, median nerve (PubMed Search)

Posted: 8/8/2020 by Brian Corwell, MD (Updated: 8/17/2022)
Click here to contact Brian Corwell, MD

Pronator Teres Syndrome

 

A compressive neuropathy of the median nerve in the region of the elbow

The median nerve passes through the cubital fossa and passes between the superficial and deep heads of the pronator teres muscle.

Rare compared to other compressive neuropathies such as carpal tunnel syndrome.

More common in women and in fifth decade of life

May be seen with weight lifters, arm wrestlers, rowers, tennis, archery, professional cyclists, dentists, fiddlers, pianists, harpists

Also associated with well-developed forearm muscles  

History:

Forearm pain – unlike carpal tunnel

Paresthesias in median distribution

No night symptoms – unlike carpal tunnel

Physical exam:

Sensory loss in medial nerve distribution.

Involves the thenar eminence!

Unlike carpal tunnel syndrome which doesn’t involve sensory loss in thenar eminence.

Pain may be made worse with resisted forearm pronation

Compression/Tinel’s sign over pronator mass reproduces symptoms

Treatment:

Splinting which limits pronation and NSAIDs

Steroid injection

Surgical nerve decompression is non operative treatment fails after greater than 6 months (rare)

 

 


Category: Orthopedics

Title: Treatment for carpal tunnel syndrome (CTS)

Keywords: carpal tunnel syndrome, neuropathy, (PubMed Search)

Posted: 7/11/2020 by Brian Corwell, MD (Updated: 8/17/2022)
Click here to contact Brian Corwell, MD

Treatment for carpal tunnel syndrome (CTS)

The management of CTS depends of the severity of the disease

If symptoms or on the mild to moderate range, a trial of conservative treatment is encouraged.

Possible therapeutic approaches can include splinting in wrist neutral position. Some even extend to keep the CMP joints extended. Extreme flexion and extension can increase pressure within the carpal tunnel. Usually for nighttime use only. May be used during day based on work and activity demands.

Has been shown to improve electrophysiologic findings after 12 weeks of use in moderate CTS.

Formal hand physical therapy (by an experienced therapist) may also be of some benefit including carpal bone mobilization, ultrasound and nerve glide exercises.   

There is small evidence for the benefit of prednisone (20mg/d) as it has been shown to be more effective than placebo with improvements lasting an average of 8 weeks.

There is no benefit to NSAIDs or diuretics.

There is poor evidence for therapeutic ultrasound and acupuncture.

While more invasive than the above modalities, steroid injections may decrease inflammation and pressure in the carpal tunnel.  Patients randomized to steroid injection may do better than those randomized to nighttime splinting.

Early referral in those with positive electrodiagnostic findings is encouraged as they do best with earlier surgical release and have better recovery.

If however the patient has severe, progressive or persistent symptoms or there is known evidence of nerve injury on diagnostic testing, referral for surgical decompression is warranted.

 


Category: Orthopedics

Title: Sickle cell trait and exertional death

Keywords: Sickle cell trait, exertional death (PubMed Search)

Posted: 6/13/2020 by Brian Corwell, MD (Updated: 8/17/2022)
Click here to contact Brian Corwell, MD

Sickle cell trait (SCT) is common and often overlooked clinically

               -7.3% African Americans

               -0.7% Hispanics

               -0.3% Caucasians

 

SCT is a leading cause of exertional death in athletes who play football

The exact mechanism is unknown but likely involves a combination of high intensity exercise, dehydration, heat strain and inadequate opportunity for cardiovascular recovery leading to microvascular erythrocyte sickling.

This leads to hypoxia, cell death, hyperkalemia, and death from arrhythmia.

Presentation often involves rhabdomyolysis and exertional collapse.

In August of 2010 the NCAA enacted legislation requiring documentation of SCT status of all Division 1 athletes (2012 for Division 2 and 2014 for Division 3)

They also mandated education, counseling and issued guidelines for proper conditioning

Sudden death in athletes with SCT was first observed in military recruits in 1970.

Death in African American military recruits was 28 times more likely in those with SCT than in those without.

A 2012 study of football athletes found the risk of exertional death to be 37 times higher in athletes with SCT than in those without.

Despite game/competition situations being more intense, deaths occur almost exclusively during practice and conditioning drills.

Following the 2010 legislation, there has been a 89% decrease in death from SCT in NCAA D1 football.

Workout plans need to account for heat/humidity, the athletes level of conditioning and allow for adequate rest, recovery, hydration. SCT screening is only part of the solution.

 

 

 

 

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Category: Orthopedics

Title: Post concussion musculoskeletal injuries

Keywords: Concussion, musculoskeletal, injury, lower extremity (PubMed Search)

Posted: 5/23/2020 by Brian Corwell, MD (Updated: 8/17/2022)
Click here to contact Brian Corwell, MD

Post concussion musculoskeletal injuries

Sport related concussion (SRC) impairs numerous functions of the CNS.

Traditional research has focused on risk of repeat concussion following clearance and return to sport

Several studies have shown a consistent elevated risk of lower extremity injuries from 90 days up to one year following SRC.

These include lateral ankle sprains and ACL injuries. Risk ranges, 1.3-3.4x.

This risk may be greater in those with multiple concussions.

This elevated rate has been seen in populations ranging from high school, college to professional athletes and has also been seen in the general population.

Persistent neurological deficits in cognitive and postural control, stability and gait deviations have been postulated as potential mechanisms.

These may be potential modifiable risk factors before return to play/activity. This may be a role best served by sport physical therapists to assist with sport specific rehabilitation post concussion.