non-surgical options to augment physical therapy

what is the role of primary care sports medicine?

non-operative evaluation and management of acute and chronic musculoskeletal injuries and conditions

evaluation and management of sports-related injuries like concussions

performance optimization: nutrition, REDS

when should someone be sent to a sports medicine physician?

second opinion

reassurance before progressing rehab

imaging

lab to rule out systemic pathology/inflammatory arthritis

augment rehab (OMT, bracing, oral meds, injection, etc)

what are xrays used for?

knee OA

shoulder

ankle if mobility is not improving (coalition)

what is MRI used for?

assess severity (stress fx and return to running)

pathology amenable to surgical intervention (internal derangement of knee and labral tear)

what is ultrasound used for?

diagnostic: hamstring strain, grade severity, assess for hematoma

image guidance for procedures: hip joint, baker's cyst, PRP, prolo, hydrodissection

when is a CT used?

rare

for rib or thoracic region (motion artifact with MRI)

when would labs/blood work be indicated?

decreased exercise tolerance and/or abnormal appearance of joints

what is included in labs/blood work?

(CBC) cell counts: infection, inflammation, anemia

iron status (iron studies, ferritin)

vitamin D

sed rate, CRP, RF, ANA, Lyme's (inflammatory arthritis, autoimmune condition)

what prescription medication management is used for analgesics?

NSAIDs topical or oral (diclofenac, celebrex, meloxicam)

what prescription medication management is used for neuropathic pain?

gabapentin and duloxetine

what prescription medication management is used for post concussion?

headaches (TCAs) --> nortriptyline

mood (SSRIs/SNRIs) --> venlafaxine/effexor

inattention (stimulant) --> adderall, ritalin

what procedures can be performed

bracing, splinting, casting

osteopathic manipulative treatment (OMT)

injections

what are some reasons for bracing, splinting, and casting?

immobilize, limit mobility

decrease pain

prevent further injury

facilitate healing

what are some different bracing options?

walking fracture boot for metatarsal stress fracture

hinged knee brace - MCL sprain

metagrip for CMC joint OA

what is a general indication for splinting?

initial immobilization for fracture management (while still swelling)

when are splints used with medicare?

when medicare does not cover cost or allow dispense of DME (braces), can use a splint or cast instead

when is casting utilized?

definitive management for some fractures after acute swelling resolved or if needed for game play

what are common fractures requiring casting?

metacarpal fx (boxer's fx)

salter harris I (growth plate)

what is OMT?

manual technique to improve motion and function, commonly utilizing muscle energy

same as PNF

what are diagnostic injections?

Inject local anesthetic (e.g., lidocaine) to identify which structure is generating the pain.

SA bursa v AC joint v GH joint

Aspirate for fluid analysis:

Gout, infection

what are therapeutic injections?

Inject medication:

Corticosteroid (CSI)

Hyaluronic Acid (HA)

Prolotherapy (Prolo)

Platelet Rich Plasma (PRP)

Aspirate baker's cyst, ganglion cyst

what are different therapeutic injectates?

Corticosteroids

Hyaluronic Acid (HA) aka Viscosupplementation

Orthobiologics: Prolotherapy (Prolo) and Platelet Rich Plasma (PRP)

what are benefits associated with corticosteroid injections?

Decreases inflammation & swelling > decreases pain, improves function

1. Suppresses the migration of leukocytes and macrophages (inflammatory)

Less release of vasoactive kinins

2. Limits capillary dilation and permeability (less swelling)

3. Inhibits the release of destructive enzymes that attack the injury debris and destroy normal tissue indiscriminately.

what are corticosteroid injections typically helpful for?

Particularly helpful for inflammatory arthritis

Gout

Rheumatoid Arthritis, JIA --> may induce remission

what can corticosteroid injections be used to treat?

Tenosynovitis --> De Quervain's (radial styloid), Long Head of Biceps

Trigger Finger

Morton's neuroma

Adhesive capsulitis

Shoulder impingement

Osteoarthritis (OA) --> Knee, hip, shoulder (GH, AC), CMC joint

when should corticosteroid injections be considered? how long do they last?

Consider when pain is interfering with ADLs, leisure activities, fitness

Use as adjunct to rehab

Lasts about 6 weeks

May repeat in 3 months

what are adverse effects of corticosteroid injections?

Repeated injections may cause cartilage and tendon degeneration

May be ok if replacement is next step

Transient elevation of blood sugar

what is hyaluronic acid? when is it indicated?

Gel-like - lubricates

Reduces pain by helping with shock absorption and decreasing inflammation

indicated for mild to moderate knee OA

how long does viscosupplementation last?

Single injection or weekly for 3-5 weeks

May take longer to notice improvement in pain versus steroid --> peak response 6-8 wks

May last longer than steroid --> 6 mo

what are benefits associated with orthobiologics?

Use of biological substances to enhance healing of orthopedic injuries or alter the natural course of an orthopedic disease

Target the inflammatory phase of the healing cascade

Encouraging a transition to proliferation and remodeling

May help heal ligament, tendon & muscle injuries

May reduce pain & improve function for chronic conditions like osteoarthritis

true or false: orthobiologics can reverse degenerative conditions

false, may only slow progression and delay joint replacement

what are the phases of ligament and tendon tissue repair?

bleeding --> inflammation --> proliferation --> remodeling

what is prolotherapy?

Proliferative therapy

Hyperosmolar dextrose injection

Triggers the inflammatory cascade and healing

Targets fibro-osseous junctions or entheses

what can prolotherapy be used for?

Tendinopathy: Common extensor (lateral epicondylitis), Achilles

Degenerative joint pain: Knee OA

what does recovery look like with prolotherapy? how many infections are typically required?

Recovery: 3 days of taking it easy, then back to activity

Usually requires 3 injections, 4-6 weeks between injections

what is platelet rich plasma?

Blood plasma containing a higher concentration of platelets, which contain cytokines and growth factors

what growth factors are released from platelets? how do they aid in helaing?

Growth factors (GF) modulate inflammation and healing

Activate inflammation: PDGF (platelet derived), TGF beta (transforming)

Aid in tissue repair: bFGF (Fibroblast), VEGF (vascular endothelial)

Stimulate growth of normal cells or tissues (anabolic): IGF (Insulin-like)

what is the function of PRP?

Controls pain, improves function

Improved function at 3, 6 and 12 mo post-injection

Long-term pain benefit beyond 6 mo

Functional improvements beyond 6-12 mo

May slow the progression of knee OA and delay need for knee replacement

what is the downside to PRP?

costly

procedure is painful

longer recovery: 3 days no activity, 2 weeks ADLs, 4-10 weeks progressing through therapy and easing into activity, may take up to 12 weeks before full recovery (not ideal in-season)

what is a trigger point?

Myofascial pain, muscle spasm

Trigger point = tender, discrete area of hypertonic muscle that reproduces and refers pain

what is a trigger point injection?

Insert needle into trigger point

Local twitch response to needle

Inject anesthetic (lidocaine).

Redirect needle in several planes and repeat.

what are benefits of a local twitch response?

Temporary relaxation of the muscle

Improves blood flow

Breaks pain-tension cycle

what is hydrodissection? when is it commonly used?

inject 5% dextrose around a nerve to separate it from surrounding tissue

Carpal Tunnel Syndrome: separate median nerve from flexor retinaculum, connective tissue & flexor tendons

Other nerve entrapments: Ulnar nerve at elbow (cubital tunnel), Lateral femoral cutaneous nerve below inguinal ligament (meralgia paresthetica)