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Sports Medicine for Primary Care Physicians Dr. Donald W. Kucharzyk The Orthopaedic, Pediatric & Spine Institute Crown Point, Indiana.

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Presentation on theme: "Sports Medicine for Primary Care Physicians Dr. Donald W. Kucharzyk The Orthopaedic, Pediatric & Spine Institute Crown Point, Indiana."— Presentation transcript:

1 Sports Medicine for Primary Care Physicians Dr. Donald W. Kucharzyk The Orthopaedic, Pediatric & Spine Institute Crown Point, Indiana

2 Sports Medicine for Primary Care Physicians zPediatric Athletic Sports Related Injuries zFemale Athletic Sports Injuries zPreventing Sports Injuries in Female Athletes zCOX-2 Specific Inhibitors: Emerging Role in Sports Medicine

3 Sports Medicine for Primary Care Physicians Musculoskeletal Overuse Syndromes

4 Sports Medicine for Primary Care Physicians zIncreased Musculoskeletal stress is common in our young athletes recently zReflects the escalating intensity of training and competition at younger ages zAthletes go from one sport to the next with prolonged seasons and little rest zExcessive use produces unresolved stresses on normal tissues that has yet to adapt and leads to failure and overuse

5 Sports Medicine for Primary Care Physicians zOveruse injuries occur at two particular times during training zFirst occurs when underused athletes who are partially conditioned are placed in demand situations: pre-season football and cross country zSecond occurs in the extremely fit athlete who are participating in multiple sports resulting in depletion of tissue reserves

6 Sports Medicine for Primary Care Physicians zHistory is the best primary aid to the diagnosis of overuse injuries zMechanical Pain that is produced by activity and relieved by rest is the hallmark anatomic factor zEnvironmental factors such as playing surfaces and equipment play a role zThe most significant factor though is the training programs: sudden increases or changes

7 Sports Medicine for Primary Care Physicians zOveruse treatment protocol involves five phases: zIdentify risk factors zModify offending factors zInstitute pain control zUndertake progressive rehabilitation zContinue maintenance to prevent re-injury

8 Sports Medicine for Primary Care Physicians Stress Fractures zStanitski proposed the etiology to be the result of highly concentrated eccentric and concentric muscle forces acting across specific bones and compounded by specific sports specific demands predispose the bone to failure zLoss of normal time frame for bone repair submaximal trauma produces the fracture

9 Sports Medicine for Primary Care Physicians zMuscle fatigue also plays a role in stress fractures zWith fatigue of the muscle envelope, greater stress is absorbed by the underlying bone and predispose to stress fractures zIncreased muscle force--change in remodeling rate--resorption and rarefaction--microfractures--stress fx

10 Sports Medicine for Primary Care Physicians zStandard radiographs are not helpful because early phase stress fractures are radiographically silent zBone Scans are extremely helpful but may not be positive till days post injury zLocations involve primarily the tibia but also has been seen in the upper extremity such as the humerus and radius; and proximal femoral neck

11 Sports Medicine for Primary Care Physicians zTreatment regime involves immobilization via a pneumatic leg brace: this helps distribute the stress across the soft tissue envelope that will diminish stress across the fracture and allow healing to progress zPost healing rehabilitation is critical as well as evaluating the mechanics of the injury and training/conditioning and gait too.

12 Sports Medicine for Primary Care Physicians Stress Injuries of the Growth Plate zMust be aware that chronic stress injuries can cause physeal damage zRunners show this manifestation in the distal femur and proximal tibia--attention to history, clinical exam, and xray evaluation important..confused with neoplasm zAreas Affected Include: Proximal Humerus commonly seen in Pitchers

13 Sports Medicine for Primary Care Physicians zGymnasts have the most common physeal stress fracture seen affecting the distal radius--will retard growth and produce an overgrowth of the ulna and wrist pain zTreatment is rest, immobilization, avoidance, rehabilitation, and conditioning zTreatment course involves at least 3 months of avoidance and then rehabilitation

14 Sports Medicine for Primary Care Physicians Little League Shoulder zMicrotrauma and overuse to the upper extremity localized to the proximal humerus zMechanics of pitching produces stress across the physis during the cocking phase, acceleration phase, and the follow-through- greatest stress on physis at this time zRadiographs reveal widening of the proximal humeral physis

15 Sports Medicine for Primary Care Physicians zTreatment is rest from throwing for the remainder of the season plus a vigorous preseason conditioning program the following year zRecommendation to the family involves the evaluation of the athletes throwing mechanics, in immature pitchers development of skill and control, then with maturity develop speed and velocity

16 Sports Medicine for Primary Care Physicians Little League Elbow zMedial elbow pain in tennis players, javelin throwers, and football quarterbacks zComplex grouping of injuries involving medial epicondylar fractures, medial apophysitis, and ligamentous injuries zPain is the most common complaint zDuration of pain aides in the diagnosis

17 Sports Medicine for Primary Care Physicians zShort duration: must consider avulsion fx zLonger duration: consider ligamentous injury or medial apophysitis zRadiographs lead to the diagnosis in fractures, but normal variants must be understood especially medially zMRI gaining importance in use in these injuries as it gives great details of all the structures

18 Sports Medicine for Primary Care Physicians zTreatment is diagnosis specific: *Medial Apophysitis-medial pain,diminished throwing effectiveness, and decreased distance: rest (4-6 weeks), NSAID, ice, gradual return to conditioning and resume throwing at about 8 weeks *Medial Epicondylar Fractures-nondisplaced treat with cast and rehab; displaced 3mm or more treat with ORIF

19 Sports Medicine for Primary Care Physicians *Medial Ligament Rupture-sudden onset of severe pain with instability; treatment is via direct surgical repair and if tenuous then supplement with a palmaris longus graft

20 Sports Medicine for Primary Care Physicians Panners Disease zOsteochondrosis of the capitellum (necrosis or fragmentation followed by recalcification) zSeen in children aged 7 to 12 years of age zDull,ache that is aggravated by activity especially throwing zPain always LATERAL zRadiographs reveal fragmentation and irregularities of the capitellum

21 Sports Medicine for Primary Care Physicians zTreatment involves initially rest, avoidance of throwing, and splinting until pain and tenderness subsides zRehabilitation and reconditioning of the upper extremity post recover important zLate deformity and collapse of the articular surface of the capitellun uncommon

22 Sports Medicine for Primary Care Physicians Iliac Apophysitis zIliac crest tenderness on palpation and muscular contraction seen primarily in adolescent long distant runners zNo local trauma but history of extensive intensive training programs zRadiographs are normal zTreatment is rest (4-6weeks), ice, NSAID, progressive return to sports

23 Sports Medicine for Primary Care Physicians Osgood-Schlatter Disease zClassic presentation is seen in preteen or early teenage children with activity related discomfort, swelling, and tibial tubercle tenderness zBilateral occurrence in 20 to 30% zEtiology is submaximal repetitive tensile stresses acting on an immature patellar tendon-tibial tubercle junction

24 Sports Medicine for Primary Care Physicians zMuscle imbalance is commonly seen with weakness in the quadriceps sometimes significant zTreatment is avoidance of activity, rehabilitation of the weak quadriceps, hamstrings and flexibility training, and progressive return to sports zFamily must understand that it can take from 12 to 18 months for all symptoms to subside

25 Sports Medicine for Primary Care Physicians Sinding-Larsen-Johansson Disease zAnterior knee pain at inferior pole of the patella zSeen commonly in 10 to 12 year olds zTenderness seen at the inferior end of the patella at the tendon-bone junction zMust evaluate for sleeve fracture or patellar stress fractures if history of sudden onset

26 Sports Medicine for Primary Care Physicians zTreatment involves rest, ice, NSAID, and occassionally a knee sleeve for protection zRehabilitation program to promote flexibility, quadriceps and hamstring conditioning, and return to normal activities to tolerance

27 Sports Medicine for Primary Care Physicians Slipped Capital Femoral Epiphysis zMost common hip disorder seen in adolescent zSlippage of the proximal femoral epiphysis zSeen in two body types: tall, slender, rapidly growing or the short, obese child zBilateral in 50% zCommon cause of anterior thigh or knee pain, athletes with knee pain should have the hip evaluated too

28 Sports Medicine for Primary Care Physicians zGait abnormality is the common initial presenting complaint with a limp seen zExternal rotational deformity of the hip seen (obligatory external rotation) zPain can be seen: under 3 weeks (acute); over 3 weeks (chronic) zTreatment is immediate percutaneous hip pinning

29 Sports Medicine for Primary Care Physicians Patello-Femoral Malalignment zCommon source of sports disability especially in jumpers and those sports requiring rapid changes in direction zMay be related to congenital, acquired such as in Downs or Ehlers-Danlos syndrome, or acquired due to trauma zCan be seen in association with flexible flat footedness due to valgus thrust on the patella

30 Sports Medicine for Primary Care Physicians zCommon symptoms include vague, localized anterior knee discomfort zSeen following prolonged sitting, stair accent and descent, and with increase levels of activity zClinically evaluate for mechanical alignment of the lower extremity, movement of the patella on flexion/extension, quadriceps function and size, hamstring function and overall flexibility

31 Sports Medicine for Primary Care Physicians zGait analysis for femoral anteversion or tibial torsion should be studied as well as the evaluation for flexible flat footedness zRadiographic evaluation involves plain x- rays with Merchant view to see patellar alignment and position zTreatment is symptomatic via rest, NSAID, physical therapy and sometimes bracing

32 Sports Medicine for Primary Care Physicians zRehabilitation is the key to preventing the reoccurrence of the condition zFailure to respond with prolonged symptoms and persistent subluxation with pain may benefit from arthroscopic lateral retinacular release zLong term sequlae may predispose the patient to the development of chondromalacia patella

33 Sports Medicine for Primary Care Physicians Osteochondritis Dissecans zLesion of bone and articular cartilage of uncertain etiology that results in delamination of subchondral bone with articular cartilage mantle involvement zPeak appearance is seen in early adolescence with male predominance 3:1 zSeen in the knee but can also be seen in the ankle involving the talus and the patella

34 Sports Medicine for Primary Care Physicians zClinically presents with vague knee pain that is aggravated with sports, intermittent swelling seen, and at times a feeling of the knee locking zPhysical exam is nonspecific zRadiographic evaluation includes x-ray's and if indicated an MRI zMost importantly, must differentiate acute lesions from silent chronic lesions

35 Sports Medicine for Primary Care Physicians zTreatment geared to eliminate the pathologic process and clinical condition via repair or resection of the lesion zChronic lesions loose bodies require removal arthroscopically and debridement of the bed zAcute lesions require drilling of the bed and fixation arthroscopically to allow the lesion to heal

36 Sports Medicine for Primary Care Physicians zPatellar osteochondritis is treated similar to that of femoral osteochondritis with arthroscopic evaluation and debridement and curettage of the lesion zLesion commonly seen in the lower third of the patella and is due to increased patello- femoral contact force during flexion in the presence of weak quadriceps and minor trauma

37 Sports Medicine for Primary Care Physicians Ligamentous Injuries zCommon in Athletes zLoaded in tension to provide both static and dynamic support to the knee zKnee has motion that occurs in three planes and requires this static and dynamic support zKinematics of the Knee shows that any one plane motion is always coupled with a second plane motion

38 Sports Medicine for Primary Care Physicians zMust Understand the Healing Process of the different ligaments zCollateral Ligaments have a rich blood supply from the surrounding tissue and heals well with conservative care zCruciate Ligaments have a sparse blood supply from surrounding tissue and bone attachment and do not heal well with conservative care

39 Sports Medicine for Primary Care Physicians zHealing process begins with fibrin clot formation and then a local inflammatory response zFirst week post: local vascular and fibroblast proliferation zSecond week post: fibroblasts become organized into a parallel network zThird week post: tensile strength increases

40 Sports Medicine for Primary Care Physicians zEighth week post: normal appearing ligament is now present zEarly range of motion critical to increasing the strength and energy-absorbing capacity of the ligament zImmobilization not favorable to healing and recover of the ligament

41 Sports Medicine for Primary Care Physicians Medial Collateral Ligament zPrimary restraint to valgus stress zCommonly injured by a direct blow to the lateral side of the knee with the foot planted zClinical signs reveal tenderness at the medial epicondyle with localized swelling zPain on valgus stressing or laxity seen define the grade of injury

42 Sports Medicine for Primary Care Physicians Lateral Collateral Ligament zPrimary restraint to varus stress zCommonly injured with direct blow to the medial side of the knee with the foot planted zClinical signs reveal tenderness over the lateral epicondyle with localized swelling zPain with varus stressing or laxity reveal the grade of injury

43 Sports Medicine for Primary Care Physicians Treatment of Collateral Injuries zGrade I do not require bracing, Grade II and III require the use of a hinged ROM brace with motion limited at 10 to 75 deg. initially for the first three weeks zEarly therapy important and include patellar mobilization, isometric quadriceps and hamstring exercises with modalities of whirlpool, E-Stim., and biofeedback

44 Sports Medicine for Primary Care Physicians zBracing discontinued for Grade II and III at four weeks and achieving full ROM is now the goal zOnce FULL ROM achieved then begin flexibility and strengthening program zProgram includes: leg presses, mini-squats, resisted knee flexion, proprioceptive training and swimming leading to a sports- specific training program (return 2-8 wks)

45 Sports Medicine for Primary Care Physicians Anterior Cruciate Ligament zPrimary stabilizer to anterior displacement of the tibia on the femur zSecondary role is in the control of rotation of the tibia on the femur and to aide in varus-valgus stability zCommon mechanism of injury is a twisting force to the knee accompanied by a varus, valgus, or hyperextension stress to the limb

46 Sports Medicine for Primary Care Physicians zClinically feels a pop in the knee zInability to continue to play with a difficult time putting weight on the limb zGradual onset of swelling over the next 24 hours (acute swelling think chondral fx.) zExamination reveals a positive Lachman Test, positive Drawer sign, and Pivot-Shift sign zEvaluate for other associated injuries

47 Sports Medicine for Primary Care Physicians Non-Operative Treatment zGoal is functional stability zInitially reduce pain and swelling with NSAIDS, PT, and crutches zImmobilization not necessary zIntermediate rehabilitation involves ROM, gait training, strengthening and proprioceptive training

48 Sports Medicine for Primary Care Physicians zOnce effusion down and ROM full, then begin swimming and bicycling followed by light jogging zLate phase rehab includes functional training zReturn to sports: 6 to 12 weeks zMust attain 90% of the unaffected extremity strength before return to sports zBracing is not absolutely indicated (no evidence to support functional bracing)

49 Sports Medicine for Primary Care Physicians Anterior Cruciate Ligament zIsolated disruptions are unusual in children zTwo types exist: nontraumatic cruciate insufficiency and post traumatic cruciate insufficiency zNontraumatic Insufficiency have inherent joint laxity of the knee as well as other joints

50 Sports Medicine for Primary Care Physicians zPositive anterior drawer sign but firm end point on Lachman test zFindings are seen bilaterally zAthletic participation should be limited zMost will be asymptomatic with activity modification

51 Sports Medicine for Primary Care Physicians Traumatic Anterior Cruciate Insufficiency zCan be seen in traumatic avulsions of the tibial eminence with positive radiographic findings zLaxity is commonly seen with acute hemarthrosis and often associated with damage to the supporting ligaments and meniscus zTreatment involves arthroscopic evaluation, reduction and internal fixation via bioabsorbable pins and casting

52 Sports Medicine for Primary Care Physicians Isolated Anterior Cruciate Ligament zDivided into two groups: those without functional instability and those with zIn those without limitations, conditioning and participation in sports without limitations can occur zIn those with limitations, thorough evaluation for other associated injuries must be undertaken MRI and Plain X-ray's

53 Sports Medicine for Primary Care Physicians zArthroscopic evaluation is carried out to evaluate the site and magnitude of the ACL tear and if any peripheral meniscal lesions are seen then repair carried out zIf avulsion from tibia or femur found then primary repair performed regardless of age zIf midsubstance tear with growth left, conservative treatment undertaken zIf no growth left evaluate sport situation

54 Sports Medicine for Primary Care Physicians zConservative treatment involves rest for 7-10 days, progressive range of motion over next four weeks, quadriceps and hamstring conditioning exercises are begun zMaintenance program instituted and a functional brace provided and wait until skeletally mature for reconstruction zSkeletally mature and achieved goals of rehabilitation then return to sports without brace

55 Sports Medicine for Primary Care Physicians zIf ACL torn and functionally impaired with little growth left, then reconstruction performed zTreatment geared to prevent further damage to the joint, meniscus, and articular cartilage zSurgical techniques multiple and center around the use of the patellar tendon or semitendinosus/tendon graft transfer

56 Sports Medicine for Primary Care Physicians Guidelines for ACL Treatment zPhysiologically young person who remains active in sports and will not modify activities, surgical intervention if not skeletally immature; if immature wait till maturity zSurgery for those with associated risk factors for instability such as collateral ligament tears or meniscal tears zOlder athlete modify activity and conservative

57 Sports Medicine for Primary Care Physicians Female Sports Related Injuries zShoulder Instability zPreventing Knee Injuries zPatellofemoral Problems in Women zPreventing Exercise-Related injuries

58 Sports Medicine for Primary Care Physicians Shoulder Instability zShoulder instability in the female athlete is a difficult problem to identify zIdentifying the type of instability is the biggest challenge faced zTraumatic versus ligamentous laxity zLigamentous Laxity is the more common and seen with pain as the predominant complaint

59 Sports Medicine for Primary Care Physicians zSex differences put the female athlete at risk for shoulder injuries zWomen have shorter upper limbs relative to total body length and thus upper girdle musculature and limbs work harder in certain sports ie. Swimming zShorter limb and lever arm tends to promote capsular laxity compared to men and increases stresses on the shoulder girdle increases instability and capsular laxity

60 Sports Medicine for Primary Care Physicians zIdentify Instability by the mechanism of injury, by the degree of instability, direction of dislocation or subluxation, and type of onset zTypes seen: Acute Dislocation,Recurrent Instability,Atraumatic Instability, and Repetitive Microtrauma zMost Common Type seen in the female athlete is the nontraumatic microinstability or subluxation injury due to capsular laxity

61 Sports Medicine for Primary Care Physicians zAcute Dislocation: due to trauma with anterior dislocation seen in 95% of the cases zDislocations can cause anterior detachment of the labrum or capsule from the glenoid Bankart Lesion zLesion associated with increased ligament laxity, stretching of the capsule, and loss of labrum-mediated stabilizing support

62 Sports Medicine for Primary Care Physicians zRecurrent Instability: due to repeated glenohumeral dislocations or subluxation that stretch the capsule and ligaments, leading to increased laxity and instability zResultant Natural History of chronic dislocations with unhealed Bankart lesions zSecondary Etiology: Congenital Inherent Laxity of the shoulder joint (Genetic)

63 Sports Medicine for Primary Care Physicians zAtraumatic Instability: typically a micro- instability or a subluxation disability zReferred to at times as multi-directional instability due to the movement of the head abnormally in multiple planes zGeneralized laxity of the capsule and ligaments seen with associated fraying of the glenoid labrum

64 Sports Medicine for Primary Care Physicians zRepetitive Microtrauma: commonly seen in athletes that participate in excessive overhead motions zDamages the anterior stabilizing structures of the shoulder joint zIf associated with congenital joint laxity, then pain due to impingement of the rotator cuff is also seen

65 Sports Medicine for Primary Care Physicians zClinical History will give clue to cause and the possible etiology zPhysical examination evaluates passive and active motion, palpable pain location, instability signs such as inferior instability test, anterior-posterior instability test, apprehension test, anterior relocation test(Jobe),and axial load test zImaging: X-ray's and MRI

66 Sports Medicine for Primary Care Physicians Treatment zAcute Dislocation: Reduction of the dislocation followed by immobilization for three to four weeks and the rehabilitation zEmphasis placed on early and safe ROM for the first six weeks followed by strengthening of the dynamic stabilizers of the shoulder and capsule zReturn to sports weeks

67 Sports Medicine for Primary Care Physicians zAtraumatic Instability: cornerstone is rehabilitation with specific strengthening of the muscles that protect the shoulder joint from instability and discomfort zSports specific rehabilitation is the KEY zImportantly, restrict those motions that elicit pain and promote those that do not zFailure requires workup and possible shoulder stabilization procedure (arthroscopic)

68 Sports Medicine for Primary Care Physicians Prevention zEssential Elements to Prevention: strengthening the muscles of the shoulder girdle and structured pre-sport and sport specific strength training activities zAvoid weight training with the load above the shoulder as well as avoiding weight machines due to design, and evaluate technique of the athlete

69 Sports Medicine for Primary Care Physicians Preventing Knee Injuries in Female Athletes z20,000 injuries occur in female athletes zDue to marked imbalance in hamstring and quadriceps muscle strength zHighest incidence of injury in the untrained athlete z3.6 times more likely to have an injury than the trained athlete

70 Sports Medicine for Primary Care Physicians zStrength training programs that include plyometrics, stretching, and strength training have decreased the imbalance and reduces injuries zThese program should emphasize muscle balancing, muscle re-education, and sport specific training programs and in the long run turns out to be a simple and cost- effective means to reduce injury

71 Sports Medicine for Primary Care Physicians Patellofemoral Problems in Female Athletes zAnterior knee pain in our female athletes is a frustrating problem zAtraumatic knee pain is commonly due to soft tissue overload and overuse zOccurs when the demand overwhelms the bodys ability to maintain homeostasis zFactors influence: activity changes, training errors, flexibility deficits, and weakness

72 Sports Medicine for Primary Care Physicians zClinical History will determine if the patients problems are related to anterior pain only or instability zAnterior pain is commonly worse with prolonged flexion of the knee and sitting in one position, activity related pain always seen, and symptoms aggravated by walking up or down stairs

73 Sports Medicine for Primary Care Physicians zPatellofemoral instability is identified by the feeling of the knee giving way and the knee cap feeling like its out of place zAssociated with activity but moreso full weight bearing activities that involve twisting motions zLow Energy injuries or the so called trivial injuries should alert one to the diagnosis of Patello-femoral instability

74 Sports Medicine for Primary Care Physicians zClinical examination involves careful evaluation of the knee mechanics, muscle strength and size, palpation of the knee cap, and tracking of the patella zEvaluate alignment of the leg, shape, and size as well as flexibility of the limb zEvaluate patellofemoral alignment zEvaluate pain generator coming from the patella

75 Sports Medicine for Primary Care Physicians zImaging involves: x-rays including AP,Lateral and Obliques with Merchant view to see tracking of the patella zTreatment is usually non-operative and begins with activity modification zDye Envelope of Function is a concept to achieve a balance between activity/work that a patient can do without leaving a state of homeostasis

76 Sports Medicine for Primary Care Physicians zKey Goal to treatment is to achieve a pain free envelope of function through avoidance of provocative activities until conditioning dictates a return zStrengthening should not stress the envelope and should be initially geared at the submaximal level until rehab sufficient zSpecific exercises should be performed to enhance the deficient muscle groups

77 Sports Medicine for Primary Care Physicians zQuadriceps and Hamstring Balancing exercises and conditioning critical as well as VMO exercises zStretching program is important as flexibility is key to rehab but moreso to prevention and re-education of the appropriate muscle groups zTaping beneficial during rehab but not long term…secondary deterioration of muscles

78 Sports Medicine for Primary Care Physicians zSurgical correction can be effective but after all conservative measures exhausted zArthroscopic Lateral Releases work BEST initially but without proper re-education, will deteriorate after two-three years zProximal or Distal Realignment procedures are then required with proximal muscle re- alignments better than boney procedures

79 Sports Medicine for Primary Care Physicians Pearls to Anterior Knee Pain zDetailed History zAccurate Physical Examination zFocused Initial Rehabilitation Program zDetailed Sports-Specific Conditioning Program zUnderstanding of the Long-Term Need to continue rehabilitation zNO QUICK FIXES

80 Sports Medicine for Primary Care Physicians Recommendations for Preventing Exercise-Related Injuries in Females zWomen are engaging in sports and fitness activities with increasing numbers zWomen participating in sports has grown from 300,000 three decades ago to 2.7 million today zWomen represent 33% of college athletes and 37% of US Olympic athletes

81 Sports Medicine for Primary Care Physicians z37.4 million women now perform aerobic activity on average twice each week zUnfortunately, research on exercise- related injuries in women has not kept up and the true incidence and risk factors are not known zCDC evaluated military personnel for female related sports injuries

82 Sports Medicine for Primary Care Physicians zInjury rates among military females was 1.7 to 2.2 times higher than males zFemale recruits were less fit upon entering the military service zLow aerobic fitness was found to be the greatest risk factor affecting female athletes zIncreased aerobic fitness programs decreased the incidence of injuries in recruits when done early in basic training

83 Sports Medicine for Primary Care Physicians zStudies revealed that age was not a strong risk factor for injury zOlder athletes modify there degree of intensity of exercise and thus limit their risk of injury zSmoking did influence injury rates with 1.2 times higher rate of injury in smokers compared to non-smokers zReason: delayed healing of microtrauma to tissue

84 Sports Medicine for Primary Care Physicians zBody composition also influenced injury rates in females zHigher Body Mass Index associated with increased risk due to extra load placed on body zLow Body Mass Index also seen with higher risk due to lower proportion of muscle relative to bodys bone structure, thereby putting greater stress on the bones leading to injury

85 Sports Medicine for Primary Care Physicians Strategies for Injury Prevention zWomen over 50 should consult their physician before beginning an exercise program zFrequency, Duration, and Intensity of exercise should be customized zWatch for early warning signs such as increasing muscle soreness, bone and joint pain, fatigue, and decreased performance

86 Sports Medicine for Primary Care Physicians zWhen warning signs present, reduce frequency, duration, and intensity of exercise until symptoms diminish zIf injury occurs, then sufficient time should be allowed for recovery and rehabilitation before resuming exercise activity zWomen who smoke should stop zMost importantly, set realistic goals

87 Sports Medicine for Primary Care Physicians COX-2 Specific Inhibitors: Improved Advantages Over Traditional NSAIDs

88 Sports Medicine for Primary Care Physicians zRole of NSAIDs in treating injuries has been based on their ability to inhibit inflammation and depress pain via inhibition of the enzyme: cyclooxygenase zCyclooxygenase catalyzes the first two steps in the synthesis of prostaglandins zNSAIDs(COX-1) inhibit prostaglandins but also affect other important bodily functions ie. Gastric mucosal protection, platelet aggregation

89 Sports Medicine for Primary Care Physicians zRecent Studies revealed a second gene with cyclooxygenase activity (COX-2) zThis gene primarily involved in the inflammation and pain cycle whereas the COX- 1 is moreso the housekeeping enzyme zFurthermore, COX-2 is inducible in most cells that is upgraded in inflamed tissue by cytokines and endotoxins to produce PG zCOX-1 is a constitutive enzyme seen in all cells including monocytes and platelets

90 Sports Medicine for Primary Care Physicians zThis specificity gives the COX-2 inhibitors a better and more selective effect on the inflammatory cycle without damaging the housekeeping effect needed from the COX-1 zComparative NSAIDs will influence bone and tissue metabolism through their effect on PG production and effect all aspects of healing both in fractures and injured tissue zCOX-2 being inducible, will allow the normal cascade mechanism for healing to continue

91 Sports Medicine for Primary Care Physicians zComparative NSAIDs will effect bone fracture healing, bone fusion in spinal fusion surgery, as well heterotopic ossification through effect on the COX-1 and overall effect on the constitutive enzyme needed for housekeeping zEven though COX-2 effect cytokines seen in inflammatory tissue and also the fracture model, being inducible, it will block those being produced and not those in the normal tissue cascade allowing the cycle to continue

92 Sports Medicine for Primary Care Physicians zCelebrex and Vioxx do not inhibit COX-1 and thereby do not affect the housekeeping functions of COX-1 zCelebrex and Vioxx only affect COX-2 and does not disturb the COX-1 in the GI tract and thus preserves the effect on the gastric mucosal and the protective effect of prostaglandins in the GI tract

93 Sports Medicine for Primary Care Physicians zBenefits therefore of COX-2 show a higher safe GI profile zImproved effects on pain and inflammation zNo effect on thromboxane synthesis and therefore no influence on platelet aggregation zNo effect on post-operative bleeding

94 Sports Medicine for Primary Care Physicians zFor Sports-Related Injuries it offers relief from pain and inflammation, rapid onset of action, improved quality of life and better dosing regimens zCOX-2 inhibitors are effective in treating acute and chronic pain including muscle tenderness, strains, sprains, and even fractures (potentially no effect on new bone formation) excellent effect on pain control

95 Sports Medicine for Primary Care Physicians zUse in recent studies on minimally invasive orthopaedic procedures reveals positive results especially in ACL reconstructions zRegime proved effective was: Vioxx 50mg given the morning of surgery and then 50mg daily for 4 days, then decreased to 25mg daily there after

96 Sports Medicine for Primary Care Physicians THANK YOU

97 Sports Medicine for Primary Care Physicians Dr. George Alavanja Director, Section of Sports Medicine The Orthopaedic, Pediatric & Spine Institute Crown Point, Indiana

98 Sports Medicine for Primary Care Physicians zRole of COX-2 Inhibitors on influencing bone graft arthrodesis in spinal fusion surgery: Kucharzyk,D and Cook,S. In Vivo Controlled Animal Study on the Effect of COX-2 Inhibitors on Lumbar Spinal Fusion Surgery Tulane University Clinical Research Dept. The Orthopaedic, Pediatric & Spine Institute


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