0404 HISTORY: A previously healthy 14-year-old sousaphone player presented with a 2-week history of progressive left arm weakness. He denied any preceding trauma. Review of systems was negative for pain, fever, weight loss, rash, or recent illness. He was right-hand dominant but supported the sousaphone on his left shoulder. He denied medications and his past medical history was negative. PHYSICAL EXAMINATION: Examination revealed a nondysmorphic male. His cervical spine showed full range of motion and was nontender. Spurling's test was negative. He showed increased scapular glide and winging on the left. Passive range of motion was full throughout. Active forward flexion and abduction of the left shoulder was limited to 90 degrees secondary to weakness. Strength in the left arm was 3+-4/5 including shoulder abduction, shoulder internal and external rotation, scapular plane elevation, elbow extension, wrist extension, forearm supination, thumb extension, and finger adduction and abduction. Elbow flexion, wrist flexion, thumb opposition and was 5/5 on the left. Sensation was decreased at the left lateral shoulder. Range of motion was full, strength was 5/5, and sensation was grossly intact in the right upper extremity. Deep tendon reflexes were 2+ and symmetric throughout. Strength, range of motion, and sensation was normal in the lower extremities. DIFFERENTIAL DIAGNOSIS: Brachial plexus traction/pressure injury Spinoglenoid cyst Posterior spinal column lesion Viral radiculitis-plexitis Infarction due to vasculopathy (Diabetes mellitus Parsonage-Turner Syndrome TEST AND RESULTS: C-spine AP, lateral, and lateral flexion/extension radiographs Normal, no bony abnormality, fracture, or subluxation Left shoulder radiographs Normal, no bony abnormality, dislocation, or fracture Left shoulder MRI Normal, no soft tissue mass or cyst Upper extremity EMG and nerve conduction study Denervation along the radial and axillary nerves; involving the deltoid, triceps, and extensor carpi radialis No evidence of radiculopathy, central process, or peripheral neuropathy Cervical spine MRI Normal, no evidence of a posterior cord lesion Left brachial plexus MRI Normal, no evidence of atrophy or lesion FINAL WORKING DIAGNOSIS: Parsonage-Turner Syndrome vs. Marching Band Compression Neuropathy TREATMENT AND OUTCOMES: The patient was asked to stop playing the sousaphone to avoid further compression of the brachial plexus and shoulder. He was placed in physical therapy to maintain strength and range of motion. The natural history and expected outcomes of possibe Parsonage-Turner Syndrome were discussed with the patient. He continues to be followed.
HISTORY A previously healthy 9-year-old white male presented with a 4-day history of acute onset left leg pain. The pain was described as “dull” and localized to his left hip and groin. It was constant and worse with ambulation. He had no other joint pain or back pain. He denied any injury, recent illness, fever, rash, vomiting, or diarrhea. Of note, he had starting running with his mom the week prior to the onset of the leg pain. They ran a “non-strenuous” pace approximately ½ to 1 mile every other day. In addition, he plays recreational soccer 2–3 days per week. At this point he was unable to run. There was a distant family member with JRA. PHYSICAL EXAM The patient was non-toxic and in no acute distress. He walked with an obvious antalgic gait on the left. His spine showed full range of motion and was non-tender. His upper extremities showed full range of motion, 5/5 strength, and were non-tender. His pelvis was level and non-tender to palpation. His left hip showed significantly limited range of motion with internal rotation due to pain. External rotation, flexion, and extension were full despite minimal discomfort. His right hip and remainder of both lower extremities showed full range of motion, 5/5 strength, and were non-tender. His skin was dry, intact, and without rashes. His upper and lower extremities showed 2+DTRs and normal sensation. Pulses were 2+and symmetric in both the upper and lower extremities. DFFERENTIAL DIAGNOSIS Trauma Muscle strain Stress fracture Apophyseal injury Inflammatory Toxic synovitis Myositis Juvenile rheumatoid arthritis Lyme disease Infection Septic joint Osteomyelitis Neoplastic Tumor Pediatric hip disorders Avascular necrosis-Perthes Slipped capital femoral epiphysis Developmental dysplasia of the hip TESTS AND RESULTS AP and Frog-leg pelvis radiographs: No bone or soft tissue abnormalities. Laboratory investigation:CRP, ESR, CBC, LDH, ANA normal, blood culture negative. MRI Pelvis:T1 and T2 high signal abnormalities in the left superior pubic ramus and ischium, no fracture or soft tissue abnormality. CT guided biopsy and culture of the superior pubic ramus:Bone marrow fibrosis and evidence of chronic inflammation. Culture positive for pansensitive Staph aureus. FINAL/WORKING DIAGNOSIS Chronic osteomyelitis of the left pelvis TREATMENT AND OUTCOMES Activity modification with crutches Parenteral antibiotics (4 weeks), followed by oral antibiotics (3 weeks) Within 2 weeks his pain and limp resolved After the antibiotic treatment, he began a gradual ramp up of activity and returned to full participation without complications.
The incidence of obesity and its complications in children and adolescents has increased dramatically. Resources are limited for physicians in private practice to properly evaluate and manage this epidemic. PURPOSE To implement a comprehensive management program for overweight youth in a private pediatric setting and determine its effectiveness. METHODS Fueled for Life is a comprehensive program for the management of overweight youth developed in a university setting. With minimal modifications, this program was implemented in a private pediatric practice. Outcome measures included participant and caregiver satisfaction obtained from anonymous questionnaires, participant attendance, and body weight information. Physicians in the practice also completed satisfaction questionnaires. RESULTS Over a 12 month period, eighty-seven children enrolled in the 8-week program. The participant's age range was 5–20 years with a mean age of 11 years. Participants were 40% males and 60% females. 90% of participants had a BMI equal to or above the 95th percentile for their age. 62.8% of participants attended at least 6 of the 8 behavior modification classes with 19.8% attending all 8 classes. Over 70% of the participants attended at least half of the fitness classes (available 2–3 days per week). Attendance in both the classroom discussions and the fitness classes was associated with both weight loss and weight maintenance. The average weight change for all participants was −1.02 pounds. 100% of participants indicated they enjoyed the program. 100% of participants and caregivers would recommend it to others. The majority of caregivers indicated their children were more active (95.2%), had higher self esteem (83.3%), and were making “healthier” food choices (97.6%) at the conclusion of the program. 97.6% of the caregivers indicated they had made positive changes in their own behaviors. Participants indicated they felt stronger (90.2%), faster (88.2%), and had more energy (92.2%) at the end of the program. 98% stated they were eating healthier. All 15 pediatricians in the group stated they were “very satisfied” with the program and would recommend its usage in other practices. CONCLUSION The Fueled for Life program appears to be an effective tool for physicians in private practice to utilize in the management of overweight youth. Initial outcome data appear very promising for children who participated in the Fueled for Life weight management program. More long term studies are needed to determine the program's effectiveness in combating the worrisome trend of overweight youth.
2369 PURPOSE: The purpose of this survey was to determine the nutritional knowledge, beliefs, and practices of collegiate athletes and to assess the need for a sports nutritionist at a Division I university in the Southeast. METHODS: A selfadministered anonymous nutrition survey was completed by 243 division I college athletes. Questions addressed sources of nutrition information, nutrition knowledge, and nutrition and weight management practices. Differences between genders and those who had received nutritional information were detected using chi-square tests and t-tests. RESULTS: Less than 40% of athletes surveyed reported receiving nutritional information before college. A potentially reputable source was chosen, by over 60% of both males and females, as the individual who had taught them the most about nutritionFinearly 99% of the athletes were found to have poor nutrition knowledge. Traditional nutrition plans were highly prevalent (over 68%). The majority of athletes reported consuming less than 3 servings of fruits or vegetables per day and 40% of female athletes reported consuming less than 2000 calories/day. Over 70% of female athletes reported they were currently trying to lose weight, while most male athletes were interested in weight gain or weight maintenance. Female athletes were more likely to report that a coach and/or trainer had suggested they lose weight. CONCLUSIONS: Despite the fact that most athletes report receiving nutritional information after starting college, athlete's current nutrition knowledge and practices are suboptimal. Additionally, athletes are engaging in troublesome and potentially harmful weight management practices (i.e. increased protein intake, skipping meals, supplement usage). Athletes recognize the role of good nutrition and are interested in learning more about proper sports nutrition. Coaches, athletic trainers, and team physicians, with proper training and resources, can work together with a sports nutritionist to ensure that collegiate athletes adopt more healthy and effective nutritional practices.
HISTORY A 21-year-old freshman collegiate point guard basketball player presented with left lower leg pain. By history he was an elite level player. He described pain for over two years. Non-medical personnel had told him he had “shin splints” during that time. Initially his pain would flare with increased activity and lessen with restricted play. A trial of self-imposed rest for 3 months was unsuccessful in relieving the pain. Last season, he limiting his jumping on the court and was able to play at 70 percent of normal. The pain seemed to peak just after the conclusion of activity. At the time of initial evaluation, the pain was almost constant, even while walking, and occasionally at night. He no longer was playing basketball. He denied any trauma two years ago to his leg preceding the onset of pain. He had no symptoms in his right leg. Review of systems was negative for any fever, myalgias, weight loss, or lower leg paresthesias. PHYSICAL EXAM Examination revealed an athletic appearing young male. His upper extremities showed normal strength and full range of motion. His spine was straight and pelvis level. His hips, knees, and ankles showed full range of motion. He was nontender with passive range of motion with knee flexion and extension, and ankle plantar flexion and dorsiflexion. Palpation of the right tibia and fibula was unremarkable. Palpation of the left tibia revealed a localized area of point tenderness with surrounding pain measuring approximately 2–3 cm in diameter on the anterior surface, approximately mid-shaft. There was minimal swelling, but no surrounding erythema, induration, or warmth. He had no tenderness related to the anterior compartment. His left fibula was unremarkable. He had 5/5 bilateral strength with resisted leg extension and flexion, as well as ankle inversion, eversion, plantar and dorsiflexion. Sensation was grossly intact. DTRs were 2+ and symmetric in both lower extremities. DIFFERENTIAL DIAGNOSIS Tibial stress fracture. Shin splints (inflammatory shin pain or traction periostitis) Tumor (bony or soft tissue). Recurrent exertional compartment syndrome Infection (osteomyelitis). TESTS AND RESULTS Anterior-posterior and lateral radiographs of the left lower extremity The lateral view reveals an anterior hypertrophic cortex with a 6 mm radiolucent area in the anterior cortex in the mid-shaft of the tibia. Nuclear medicine three-phase bone scan of the lower extremities Normal symmetric vascular flow. Normal blood pool image. The three hour delayed image demonstrates a focal area of intense activity in the mid-anterior diaphysis of the tibia. Computed tomography of the left tibia A focus of decreased cortical density present in the anterior aspect of the mid-shaft of the left tibia measuring approximately 8 × 13 mm is seen. This is more prominent inferiorly where the rounded lucent area measures approximately 7–8 mm in size. More inferiorly, there is a smaller area of bone loss that is almost ovoid in configuration along the anterior aspect of the left tibia. No definite periosteal reaction or significant soft tissue response was appreciated. FINAL/WORKING DIAGNOSIS Anterior cortical stress fracture of the left tibia TREATMENT AND OUTCOMES He was given crutches and asked to minimize weight bearing after the initial evaluation. The bone scan, and subsequently the CT, was obtained. After approximately 4 weeks his symptoms were unchanged. With the above results, he was given the option of continued conservative management with the addition of a bone stimulator or definitive treatment with intramedullary rod placement. He has elected for the latter out of frustration with his current condition and desire to get back out on the basketball court. He is currently scheduled for intramedullary rod placement.
FigureChronic pain affects a large number of individuals. Some of the more common chronic pain syndromes affecting individuals include degenerative spine disease, knee and hip osteoarthritis, and rotator cuff pathology. Although certain exercise modalities can help these conditions, it can be very difficult for individuals to engage in fitness because of the pain associated with each. This article contrasts acute and chronic pain, as well as the basics related to the treatment of such problems. Degenerative spine disease, knee and hip osteoarthritis, and rotator cuff disease will be highlighted as examples of chronic pain commonly seen by physicians, therapists, and fitness trainers. Suggestions will be made related to fitness and chronic pain, as well as activity modifications for these specific conditions. ACUTE INJURY CARE AND RELATED PAIN Acute pain is relatively easy to understand, and we, as a sports medicine and therapy profession, do a good job treating this. Examples would include a sprained ankle or broken bone. The old adage RIICE (Rest, Ice, Immobilization, Compression, Elevation) treatment plan applies well to many acute injuries. The injured area typically is rested for a period, initially, when pain is severe. In sports medicine, we often use the term “relative rest” for most injuries that are not severe. Individuals may be able to ride a bike instead of jogging or swim instead of playing a sport to allow for continued activity without stressing the injured area. Ice or cold compresses can help a great deal with swelling, inflammation, and the pain associated with acute injuries. This can be applied for 20 minutes every few hours. It is important to have a protective barrier between the skin and the ice. Sometimes immobilization is necessary in a splint, cast, or sling. Compression and elevation can help prevent and treat unnecessary swelling associated with the injury. The pain associated with acute injuries often is managed with acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs). Acute pain disorders respond to these modalities within a 1- to 2-month period and with little residual problems for the individual. ACUTE PAIN VERSUS CHRONIC PAIN Chronic pain is a completely different animal. When pain is present for 2 to 3 months or longer, it is termed “chronic.” Unlike acute pain that serves to protect the injured body part from further damage, chronic pain serves no known helpful purpose. Also, as opposed to the treatment of acute pain, treatment of chronic pain is much more challenging for patients and caregivers and often less successful in terms of outcomes. Common examples of chronic pain include headaches, shingles, neuropathy, degenerative spine disorders, and osteoarthritis. Chronic pain is very common, with an incidence of approximately 100 million Americans affected. More individuals report chronic pain than diabetes, coronary artery disease, stroke, and cancer combined. Chronic pain syndromes also differ from acute pain in terms of the burden on other aspects of one’s life. Social interactions, personal relationships, productivity in society, and physical and emotional health are affected negatively by chronic pain. Individuals with chronic pain often have comorbid depression and anxiety disorders. As a result of the pain and other mentioned factors, fitness levels are often poor in individuals with chronic pain. The treatment of chronic pain is a huge burden on the health care system. CHRONIC PAIN TREATMENT Chronic pain is quite a challenging disorder to treat for health care providers. Pain medicine is a specialty of its own. Pain medicine providers typically have a background in anesthesia, physiatry, neurology, and/or psychology. Sports medicine providers can be involved in the case of patients with chronic pain when the disorder affects the musculoskeletal system, in particular, the spine and joints. Chronic pain is best treated using a combination of modalities. Certain medications can at times help with pain syndromes. Antiseizure and antidepressant medications are common examples. These medications often help with neuropathic pain, and antidepressants in particular can help with comorbid depression and anxiety. Pain medications such as acetaminophen and NSAIDs help with milder pain. More significant pain may require intermittent or regular opioid use. All of these medications have a number of negative side effects. Behavioral coping strategies also have been shown to help with chronic pain syndromes. Physical therapy can help with musculoskeletal problems contributing to chronic pain. Patients are encouraged to follow a healthy nutrition plan that provides plenty of antioxidants, adequate protein, and is low in refined sugars. Sleep cycles are often disrupted in chronic pain and may require specific treatment.FigureCHRONIC PAIN AND FITNESS Exercise has been shown to help with chronic pain syndromes. It is well established that regular exercise can help with disorders such as fibromyalgia, chronic low-back pain, and arthritic conditions. That being said, it can be very difficult to convince patients with chronic pain that fitness actually will help their pain. The typical response is “I can’t exercise, it hurts too much.” Fitness plans for these individuals should take into consideration their specific problem, baseline fitness level, and ultimately their specific goals. Gentle aerobic conditioning is a good place to start, with subsequent strength training for larger muscle groups in particular. Core training can help most musculoskeletal conditions causing chronic pain. These fitness basics can be introduced in physical therapy for the painful condition. Fitness trainers can play a pivotal role, emphasizing home fitness plans after patients have graduated from physical therapy. Newer fitness strategies emphasizing training to fatigue, high-intensity training, and plyometrics may not be appropriate for individuals with chronic pain. Sports can be an excellent method to encourage lifelong fitness. However, it is important to point out that sports also can be a cause for acute injuries that could contribute to chronic pain. Individuals with degenerative spine disease, knee and hip arthritis, and chronic rotator cuff pathology often have muscle weakness that may predispose to injuries. These conditions can be made worse with repetitive minor trauma. It is critical that these individuals have a reasonable baseline fitness level if they choose to engage in sports. DEGENERATIVE SPINE DISORDERS Low-back pain is the leading cause of disability in Americans younger than 45 years. Over the age of 55 years, many individuals have chronic low-back pain as a result of a combination of issues, which in sum are termed a “degenerative spine.” The anatomical changes include the following: The intervertebral discs are often narrowed in height, bulging, and “dehydrated.” Without these discs serving as shock absorbers and providing stability in the spine, the forces are transferred to the vertebral bodies, which often leads to compression deformities and osteophytes (bone spurs). The facet joints that bind each vertebral body to one another show signs of arthritis as well with bony enlargement. The spinal nerves frequently are compressed between the discs anteriorly and ligaments and joints posteriorly. This is termed spinal stenosis. These degenerative changes (arthritis and stenosis) in the spine can hinder an individual’s attempts at exercise greatly. The arthritic changes in the spine limit spinal mobility and the spine’s ability to absorb stress. Spinal stenosis causes pain in the back or legs when patients are standing or walking. Patients can then develop stiffness and core and leg weakness, which only worsen their underlying pain. This degenerative pain cycle can be difficult to stop. Treatment is aimed at maintaining strength and flexibility in the core muscles, as well as having strategies to reduce painful episodes in terms of intensity and duration. Some patients may go on and have interventional procedures (lumbar epidural steroid injections, for example) or surgery for their pain; however, there is no cure for degenerative spine disorders. KNEE AND HIP OSTEOARTHRITIS Osteoarthritis is the number 1 joint disorder worldwide. In America, the prevalence of osteoarthritis of all joints affected nearly 27 million individuals in 2005 and this number is increasing consistently. Symptomatic knee and hip osteoarthritis affects 16% and 4.4%, respectively, of adults older than 45 years. Knee and hip osteoarthritis tends to affect females more than males, especially over the age of 50 years. Common risk factors for knee and hip osteoarthritis include obesity, sports participation, trauma, occupational hazards, genetics, and developmental disorders. The pathology involved with arthritis includes thinning of the hyaline cartilage, bony enlargement, osteophyte development, joint instability, and soft tissue inflammation. Knee and hip osteoarthritis is a common source of chronic pain and interferes with fitness because of joint immobility, secondary muscle weakness, and simply the pain itself. Nonsurgical evidence-based treatment of these conditions recently was reviewed and outlined by organizations including the American Academy of Orthopaedic Surgeons (AAOS) and the American College of Rheumatology (ACR). Some suggestions include the following: Self-management education programs (sources include the CDC, Arthritis Foundation) Activity modification Weight loss if appropriate Medications including acetaminophen, NSAIDs (oral and topical), and pain medications (opioids) for more significant pain Steroid injections for pain flares Hyaluronic acid injections for mild to moderate knee osteoarthritis It is worth noting that both the AAOS and ACR recommended against the use of glucosamine and chondroitin supplements because of their lack of current evidence. As opposed to degenerative spine disorders, joint replacement is an option for patients with severe disease and significant pain. CHRONIC ROTATOR CUFF TEARS The rotator cuff muscles in the shoulder function to help perform certain motions (elevation, internal and external rotation) and provide a secondary restraint securing the ball in the socket. Rotator cuff tears are very common, with a prevalence of about 20% of 60-year-old individuals. This prevalence increases with age. Risk factors for rotator cuff injuries include a history of trauma, male gender, and the dominant arm. For the most part, the standard of care for acute rotator cuff tears is surgical repair. Chronic tears, on the other hand, do not fair as well with surgical intervention. When the rotator cuff is not functioning, the ball can ride up in the socket, which can result in impingement. This will cause pain when individuals raise their arm more than 90 degrees. Common complaints are pain and difficulties with sleep. It is important to point out that degenerative rotator cuff tears frequently can be asymptomatic. Fortunately, there is good compensation for chronic rotator cuff tears and many patients with associated pain respond well to therapy interventions. Pain flares can be managed with activity modification, ice treatments, and intermittent pain medications. EXERCISE MODIFICATIONS FOR CERTAIN CONDITIONS Degenerative Spine Disease Water activities (water walking, water aerobics) Stationary or outdoor bike Emphasize gentle range of motion in the spine Strength training for the legs Balance training/exercises Knee and Hip Osteoarthritis Water activities (water walking, water aerobics) Stationary or outdoor bike Shorter, more frequent walking episodes Avoid deep knee bends (flexion past 90 degrees) Avoid or modify knee extension machines (terminal extension allowed) Emphasize quadriceps strength, especially with women Certain fitness methods may not be appropriate for individuals with knee and hip osteoarthritis (i.e., plyometrics) Chronic Rotator Cuff Tears Emphasize upper body posture (head high, shoulders back) Exercise the rotator cuff and scapula-stabilizing muscles, emphasize technique Avoid exercises that can strain the shoulders (deep bench press or push ups, chest flies, full dips). Keeping your hands where you can see them is a good strategy. Use caution with upper body strength training to fatigue, maximum lifts SUMMARY Chronic pain syndromes pose a significant challenge for all health care providers. Exercise has been shown to help with the pain associated with many pain syndromes. Comorbid conditions associated with chronic pain such as depression, anxiety, obesity, and poor sleep also can be helped with regular exercise. Certified fitness trainers can play an important role in emphasizing safe and effective physical activity for individuals with chronic pain caused by degenerative spine disorders, arthritis of the knee and hip, and chronic rotator cuff pathology. Individuals with these conditions should have an understanding of the problem, correct modifiable factors leading to the problem, and have a game plan for pain flares related to the condition. Exercise and proper nutrition should be considered just as important as medications, injections, or surgery for such chronic pain syndromes.
