A Dozen Sports Medicine Pearls 30+ Years of Clinical Practice ...

A Dozen Sports Medicine Pearls
from
30+ Years of Clinical Practice
Rob Johnson, MD, FACSM, CAQ Sports Medicine
Professor, Department of Family Medicine and
Community Health, UM
Team Physician, UM Athletics
Director, Primary Care Sports Medicine Fellowship,
HCMC
Objectives
• Learn from experiences of “sports medicine
veterans”.
• Use practical “tips” to improve patient care in
msuculoskeletal medicine
• Avoid potential pitfalls in the practice of sports
medicine.
#1: Pain is not the injury.
• Pain is merely a symptom of the injury.
• Treatment of pain is not treating the injury.
• Role of analgesia in recovery.
#2: Absence of pain does not imply
resolution of the problem
• Disappearance of pain – what does it mean
• What’s left
• Role of pain in recovery.
#3: All physical therapy is not created equal
• Acute injury results in:
– Inhibition (under recruitment) of the injured muscletendon
units muscle atrophy
– Over recruitment of the uninjured muscle tendon units.
– The implication Strengthen
• For the patient who has already “been to PT”,
ask
“What did you do in PT”
“What was your home exercise program”
“How many times each week did you do or are you
doing the HEP”

Because…
Rather…
• Restoring ROM
• Strengthening the injured part
Modalities
• Gradual return to training and competition
#4: The patient who isn’t improving
according to an expected time frame
• The problem…
• The solution
– Change the treatment
or
– Change the diagnosis
• Example:
– Patellofemoral disorder
– Victim
– Culprit
#5: Victim or culprit
#6: Beware the consequences of your
imaging
How about this case
The MRI
Back
– Thornbury and colleagues demonstrated a sensitivity of MRI for
herniated discs of 0.89 to 1.0 but a specificity of only 0.43 to 0.57
– Asymptomatic patients: disk bulges (52%) and protrusions (27%)
Shoulder
– Kautzner 2008: accuracy of MR for diagnosing labral tears was
68%
– Bergin 2009: MR arthrography: sensitivities of 86% to 91% and
specificities of 86% to 98%
– Clinical significance
Knee
– 61% who had meniscal tears had not had any,pain, aching, or
stiffness during the previous month.

#7: Medications – what they can and cannot
do
• Injections
– Corticosteroids
– Hyaluronic acid
– Proliferants
• NSAID’s
#8: Ordering tests
• Feel no guilt if you don’t order x-rays or lab tests!
• When ordering a test or radiograph ask:
– Will it change my treatment
– Will it change my diagnosis
#9: Non-physiologic symptoms
• My pain is “12 out of 10”
• “It’s not really painful, it’s just sore.”
• “It starts in my fingertips and ‘shoooooots’ up my
arm.”
#10: “I’ll be smarter next week.”
• Relieving factors
• How does the pain affect
work
sleep
play
• Consider the confusing constellation of symptoms
and/or physical findings.
• Nonspecific findings breed nonspecific
treatments.
• Observation is a legitimate treatment strategy to
see how the sx and signs evolve.

#11: Check the patient’ teeth
#12: Never work harder than your patient
• A compliance test of sorts.
• Especially with PT
• Who gave me this advice
• An anecdote
Summary
Good luck tomorrow, runners!
#11: Iliotibial Band Syndrome is not a
function of a “tight” IT band
• With fatigue, hip abductors (gluteus medius) fail
allowing dynamic valgus.
• With fatigue, hip ER (gluteus maximus) fail
allowing increased internal rotation.
• Result: IT Band syndrome
• Solution: strengthen hip abductors and external
rotators (Frederickson, Niemuth, and others have
confirmed the value of strengthening)