Winter 2019 edition: Sports Medicine for the Primary Care Provider

The Winter 2019 edition of Sports Medicine for the Primary Care provider was recently published. Articles in this edition include “Achilles Tendon Ruptures, “Sever’s Disease: When Bones Grow Too Fast for Tendons,” “Infectious Mononucleosis: Know the Risks” and “Research in Brief.”

A printable version of this newsletter is available here.

All articles also appear below.

Welcome

Dear Fellow Health Care Provider,

I hope this finds you well and enjoying the winter months! Here you will find the latest edition of our Primary Care Sports Medicine Newsletter, a biannual newsletter of seasonal sports topics. We hope you find the information useful and appreciate any feedback you have to enhance our efforts.

For questions, feedback and inquiries about future issues, please contact Tracie Kirkessner at tkirkessner@pennstatehealth.psu.edu or me at msilvis@pennstatehealth.psu.edu.

Enjoy,
Matthew Silvis, MD
Professor, Departments of Family and Community Medicine and Orthopaedics and Rehabilitation
Penn State Health Milton S. Hershey Medical Center

Achilles Tendon Ruptures

By Michael Aynardi, MD, Foot/Ankle Specialist at Penn State Health

The Achilles is one of the strongest and most important tendons in the body. When it snaps, as it often does in middle-aged, recreational athletes, the recovery can be lengthy and require a substantial amount of time out of work and on the sidelines.

While open surgical repair with a large incision has been the gold standard for these injuries for decades, advances in surgical technique and physical therapy could make recovery faster with fewer complications.

Two new methods for speeding up the healing process:

• Early mobilization and accelerated rehabilitation protocol. Whether a patient is treated with an open repair or a non-operative cast treatment, the early mobilization protocol has them demonstrating improved functional outcomes and faster recovery than patients who don’t mobilize quickly after surgery. Early mobilization avoids excessive gastrocnemius atrophy and tendon scarring and promotes collagen remodeling and early healing of the tendon which cuts down recovery time.
• Minimally invasive Achilles repair. These techniques require small incisions and devices that allow surgeons to capture the two torn ends of the tendon and suture them to one another. The incisions are a fraction of the length of those used in the past. Another technique involves attaching the tendon to the bone using minimally invasive methods, similar to a rotator cuff repair. Both techniques help surgeons avoid wound complications and infections which are the most common dangers of surgical treatment. Also, by creating a smaller wound with less trauma, mini-open techniques allow patients to engage in early mobilization rehabilitation.

Despite the advances, non-operative cast treatment of these injuries still plays a role coupled with an early mobilization protocol. Whether to surgically repair the Achilles is determined by many factors. In general, patients who are active, healthy and do not use nicotine benefit from a surgical repair. In patients with risk factors such as smoking, diabetes or vascular disease, the risks of surgery may outweigh the benefits of surgical intervention. Ultimately, patients should discuss with their expectations and functional demands with their orthopedic surgeons to make an informed decision.

Sever’s Disease: When Bones Grow Too Fast for Tendons

By Eldra W. Daniels, MD, MPH, Primary Care Sports Medicine Fellow, Penn State Health Milton S. Hershey Medical Center

Child athletes with heel pain might suffer from an overuse injury called Sever’s disase.

The injury, an inflammation of the calcaneal apophysis (where the Achilles tendon joins with bone), is caused by increased traction, and results in heel pain, swelling and difficulty walking. It’s similar to Achilles tendonitis, retrocalcaneal bursitis, calcaneal stress fracture, plantar fasciitis and osteomyelitis.

Named for James W. Sever, the orthopedic surgeon who discovered it in 1912, the injury is usually found in children 9 to 11 years old. The patients have likely had a growth spurt, and the bones’ growth has outpaced the tendon’s ability to maintain the patient’s flexibility.

Sever’s disease is often found in patients with weak ankle dorsiflexion, heel-cord tightness and poorly fitting footwear. Additional biomechanical forces which can predispose a patient to having Sever’s disease include genu varum, forefoot varus, pes cavus or pes planus.
Doctors probe and discover localized tenderness and swelling at the site of insertion of the Achilles tendon. Squeezing the back of the heel results in pain, and it hurts for the patient to stand on their tiptoes. Radiographs can demonstrate fragmentation, irregular ossification and sclerosis. However, since these findings are non-pathologic and can be demonstrated on the unaffected side, radiographs should not be obtained during the initial step of evaluation.

Treatment of Sever’s disease is usually rest. Corticosteroid injections and surgery aren’t recommended. A rehabilitation regimen including heel-cord stretching is essential for pain relief. Patients should be instructed to perform three sets of heel-cord stretches, holding each exercise for 20 minutes three times daily. After the pain subsides, patients should begin muscle strengthening exercises of the calf muscles, which increases the ability to absorb force and lessens the chance of symptom recurrence with return to play. The use of heel cups and properly fitting footwear will also help in treatment of Sever’s disease. If the pain does not respond to conservative treatment, a Controlled Ankle Motion boot or short leg cast can limit movement. The pain usually subsides within six to 12 months, but occasionally symptoms may last as long as two years.

Sever’s disease doesn’t cause any long-term complications or disabilities. However, the pain could return as the skeleton matures and closure of the apophysis occurs. In addition, patients and parents should not use anti-inflammatories to mask pain during sporting activities or as an attempt to speed return to play. There is MRI evidence that this condition is not an inflammation within the apophysis, but is rather a chronic repetitive injury to actively remodeling trabecular metaphyseal bone.

Infectious Mononucleosis: Know the Risks

By Lindsay Lafferty, MD, Penn State Health Milton S. Hershey Medical Center

Infectious mononucleosis, or mono, sidelines high school athletes every year. That’s not because kids who play sports are more susceptible to the disease; rather adolescent competitors are at a greater risk for one of the illness’s more serious complications – splenic rupture.

The disease starts with fatigue, sore throat, fever and swollen glands. By then, it’s invaded the lymphatic system which can cause the spleen to enlarge. For athletes, that’s a danger, because the trauma and pressure on the abdomen involved in many sports can cause the spleen burst.

It’s rare – occurring in less than 0.5 percent of patients – but an infected athlete can rupture his or her spleen without warning within 21 days of the onset of symptoms. The rate declines after four weeks, but ruptures have been known to occur up to eight weeks after an athlete first feels the malaise, fatigue and anorexia that denotes the illness’s early stages.

Worse, testing to determine whether a spleen may rupture is tricky at best. Ultrasounds and CT scans are unreliable, because the normal size of a spleen fluctuates. Without a baseline measurement, imaging cannot accurately determine if a spleen is enlarged or in danger of rupture. Physical diagnosis of splenic size identifies as few as 17 percent of cases. So deciding when the time is right for a student athlete to return to the field of play can be complex.

Onset of illness can be challenging to identify because of its long incubation period and the variable nature of its symptoms.

Epstein-Barr virus produces 90 percent of clinical infectious mononucleosis, but cytomegalovirus and toxoplasmosis can also cause clinical lymphoproliferative infectious mononucleosis. The differential diagnosis also includes group A streptococcal infection, influenza, herpes virus and acute HIV infection.

Heterophile antibody (monospot) testing is commonly used for diagnosis. False negative rates approach 25 percent in the first week of illness, but fall to 5 percent by the third week. Testing for Epstein-Barr virus early antigen and viral capsid antigens IgM and IgG can provide a more definitive diagnosis earlier in illness if needed. Positive testing for streptococcal pharyngitis does not exclude infectious mononucleosis as simultaneous infection can be seen in 30 percent of patients.

Treatment for mono includes rest, hydration and pain relievers. Acetaminophen should be used with caution given the effects infectious mononucleosis can have on the liver. Corticosteroids should only be used if there is concern for airway obstruction, painful swallowing interfering with hydration, or complications of hepatitis, myocarditis or hematologic abnormalities.

When can they play again? Recovery might take months in prolonged cases. Protective equipment, such as flank jackets or protective braces, have not been shown to reduce splenic rupture and are not recommended. Isolation is not necessary, but hand washing and avoidance of water bottle sharing can help prevent transmission.

Usually, doctors recommend resuming non-contact play and exercises that don’t include lifting weights 21 days after the illness starts. After 28 days, the patients can start to return to normal, provided the fever has subsided and the symptoms have vanished.

Research in Brief

Ballplayers’ Shoulders and Elbows at Risk

A growing number of young pitchers are ending their careers early because of elbow and shoulder injuries, according to a new study.

Findings published in the April edition of the American Journal of Sports Medicine in an article titled “Risk Factors for Elbow and Shoulder Injuries in Adolescent Baseball Players: A Systematic Review” attempt to find the causes of the phenomenon.

Researchers Ryan Norton, Christopher Honstad, Rajat Joshi, Matthew Silvis, Vernon Chinchilli and Aman Dhawan studied 19 independent risk factors for elbow and shoulder injuries in adolescent baseball players.

The results showed that age, height, playing for multiple teams, pitch velocity, and arm fatigue are clear risk factors for throwing arm injuries in young ballplayers. Pitches per game factors into shoulder injuries. Other variables are either inconclusive or do not appear to be specific risk factors for injuries.

Bioprinting Success

The advantages of 3D bioprinting on bone and cartilage restoration are the subject of a new research project.

Orthopedic surgeons Aman Dhawan and Patrick Kennedy, along side neurosurgeon Elias Rizk, and Ozbolat Lab at Penn State, examine using the technology to manufacture artificial tissue that can be used for layer-by-layer fabrication of bone and cartilage. The findings were published in the October edition of the Journal of the American Academy of Orthopaedic Surgeons in an article titled “Three-dimensional Bioprinting for Bone and Cartilage Restoration in Orthopaedic Surgery.”

The Penn State Health team has had the most in vitro and in vivo success with cartilage and bone tissue bioprinting with extrusion-based bioprinting using alginate carriers and scaffold free bioinks. Fabrication of composite tissues has been achieved, including bone which includes vascularity, a necessary requisite to tissue viability.

As the technology evolves along with high-quality radiographic imaging, computer-assisted design, computer-assisted manufacturing, real-time 3D bioprinting and ultimately in situ surgical printing, this additive manufacturing technique can be used to reconstruct both bone and articular cartilage. It has the potential to succeed where currently available clinical technologies and tissue manufacturing strategies fail.

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