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Spondylolysis: What is spondylolysis?

Spondylolysis: What is spondylolysis?

Spondylolysis is a fracture of the pars interarticularis of a vertebra (most commonly L5) that is seen in pediatric and adolescent athletes. It is generally a stress fracture that can be unilateral or bilateral.

It is more common in sports that involve repetitive hyperextension and axial loading of the spine such as gymnastics, dance, weightlifting, football, tennis, baseball. The prevalence in the general pediatric and adolescent population ranges from 4.4-4.7%.

Image taken from review article by Goetzinger. et. al. 1

Why is it important to recognize this injury?

Spondylolysis can be a common cause of back pain in the pediatric athletic population. Up to 30-40% of pediatric athletes who presents to sports medicine or orthopedic clinics with lower back pain > 2 weeks have spondylolysis. Spondylolysis, when left untreated, can lead to non-union of the defect and chronic symptoms. It can also progress to develop spondylolisthesis (slipping of the affected vertebrae over the one below it), which can lead to neurological injury to the nerve roots.

How do you diagnose spondylolysis?

History:

Spondylolysis should be strongly considered in a child who presents with sports related lower back pain, especially if the child participates in activities that involve repetitive hyperextension or axial loading of the spine. Typical symptoms include insidious onset lower back pain, with occasional radiation to the buttock or proximal/lower extremities. Pain often increases with strenuous activity or hyperextension and improves with rest. Neurological symptoms (numbness/tingling) are rare.

It is also important to ask about risk factors for metabolic etiologies of fracture such as vitamin D intake, GI absorption issues, and relative energy deficiency syndrome.

Physical exam:

  • Inspection: examine for hairy patches, sacral dimples, or cutaneous discolorations as spinal bifida occulta is a congenital risk factor for this condition. Exaggerated lumbar lordosis may also be a risk factor. Observe general posture, spinal alignment, presence of directional preferences.
  • Palpation: there may be tenderness of paraspinal muscles or localized midline tenderness. Step-off deformity may be palpated if there is spondylolisthesis.
  • Range of motion: there may be pain with extension, or limited thoracolumbar range of motion
  • Lower extremity musculature: Examine forhamstring and hip flexor tightness, as well as gluteal, hamstring, abdominal/trunk strength.
  • Neurological exam: Examine for dermatomes, myotomes, and reflexes of lower extremities to rule out the presence of radiculopathy.
  • Stork test: Standing on a single leg, hyperextension of spine may produce ipsilateral or bilateral lumbar pain

Imaging:

  • AP and lateral x-rays of lumbar spine have a sensitivity of about 75%, so this may be ordered at initial work up. Other views (such as oblique) do not improve sensitivity, and therefore are not necessary.
  • MRI is the preferred imaging method in most cases if suspicion is moderate to high and x-rays are negative.

Management:

Non-operative treatment:

  • Discontinuation of sport and avoidance of aggravating activities (especially back extension) should be instituted at the time of diagnosis to allow for bony healing  
  • A physiotherapy program may be started early if tolerated or after a period of rest if there’s significant symptoms. Physiotherapy should focus on core, pelvic and lower extremity strengthening as well as lower extremity flexibility. Lumbar extension should be initially restricted, and gradually advanced based on symptoms and healing.
  • Lumbar brace that prevent hyperextension can be considered for a period of 4-6 weeks
  • Return to play may take anywhere from 2 to 6 months, and patient should only return to competitive play if they have met physiotherapy milestones, and if they no longer have symptoms.

Surgical treatment:

Most patients improve with conservative treatment. In a small fraction of athletes who fail non-operative management, surgical referral is indicated for consideration of direct repair.

Summary:

Spondylolysis is a defect of the pars interarticularis of a vertebra (most commonly L5) that should be strongly suspected in a pediatric or adolescent athlete presenting with extension aggrevated back pain. MRI is often needed for accurate diagnosis. Treatments include cessation of sports, physiotherapy, and lumbar brace until healing of the defect. Surgical referral is indicated if there is failure of non-operative management for > 6 months.

Yuhao Shi, MD

Sports and Exercise Medicine Fellow, University of Ottawa

Advisor: Dr. Taryn Taylor, BKIN, MSc, MD, CCFP (SEM), Dip Sport Med

References 1–3

1.        Goetzinger, S. et al. Spondylolysis in Young Athletes: An Overview Emphasizing Nonoperative Management. J. Sports Med. 2020, 1–15 (2020).

2.        Berger, R. G. & Doyle, S. M. Spondylolysis 2019 update. Current Opinion in Pediatrics vol. 31 61–68 (2019).

3.        Ebraheim, N., Elgafy, H., Gagnet, P., Andrews, K. & Kern, K. Spondylolysis and spondylolisthesis: A review of the literature. Journal of Orthopaedics vol. 15 404–407 (2018).

Shoulder Impingement Syndrome: Will Surgery Make a Difference?

Shoulder impingement syndrome (SIS) is one of the most common causes of chronic shoulder pain in adults, and one that is frequently seen in primary care. Typical symptoms include pain with overhead movements, and classic physical exam tests include Neer’s sign, Hawkins-Kennedy sign, and a painful arc.

Pain from shoulder impingement is thought to be secondary to impingement of the rotator cuff tendons due to decreased subacromial space. Subacromial space can be reduced due to multiple reasons:

  • Poor posture creating a protracted shoulder girdle with internally rotated glenohumeral joint, creating a functionally reduced subacromial space
  • Subacromial bursitis, either acute or chronic (although this can also be seen secondary to the former point)
  • Spurring of the inferior surface of the acromion

Treatment of shoulder impingement syndrome typically involves:

  • Physiotherapy to develop pain-free ROM, strengthening of the rotator cuff and periscapular muscles, improved posture, and improved scapular kinetics
  • Oral NSAIDs are commonly prescribed
  • Corticosteroid injection of the subacromial bursa can be considered if pain is severe or the patient has failed a trial of more conservative management

What about surgery?

  • Arthroscopic subacromial decompression is a commonly performed surgery
  • It typically involves shaving down the inferior aspect of the acromion, thereby creating a larger subacromial space
  • A Cochrane review concluded that evidence does not support subacromial decompression surgery as a treatment for shoulder impingement, as it does not provide clinically meaningful benefits in terms of pain relief1
  • The BMJ released a clinical practice guideline strongly recommending against subacromial decompression surgery for the treatment of shoulder pain2
  • More recently, an RCT published in the British Journal of Sports Medicine that involved 5 year follow-up failed to detect any difference in pain between patients who underwent subacromial decompression, patients who underwent diagnostic arthroscopy (placebo surgery), or patients who completed an exercise program3

Bottom line?

Evidence suggests that there is no benefit to subacromial decompression surgery for the treatment of shoulder impingement. Patients with this condition should be reassured that surgery is unlikely to help their symptoms, and that treatment should focus on conservative management.

Janet Barber MD, MSc, BSc

PGY3 Sport and Exercise Medicine, University of Ottawa

Advisor: Dr Taryn-Lise Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport Med

References:

  1. Karjalainen, T. V., Jain, N. B., Page, C. M., Lähdeoja, T. A., Johnston, R. V., Salamh, P., … & Buchbinder, R. (2019). Subacromial decompression surgery for rotator cuff disease. Cochrane Database of Systematic Reviews, (1).
  2. Vandvik, P. O., Lähdeoja, T., Ardern, C., Buchbinder, R., Moro, J., Brox, J. I., … & Noorduyn, J. (2019). Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline. Bmj364.
  3. Paavola, M., Kanto, K., Ranstam, J., Malmivaara, A., Inkinen, J., Kalske, J., … & Järvinen, T. L. (2020). Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: a 5-year follow-up of a randomised, placebo surgery controlled clinical trial. British journal of sports medicine.

High Ankle Sprains

What is a high ankle sprain?

A high ankle sprain is an injury to the distal tibiofibular syndesmosis. The syndesmosis includes structures such as the anterior-inferior tibiofibular ligament (AITFL), posterior-inferior tibiofibular ligament (PITFL), interosseous ligament (IOL), inferior transverse ligament, and interosseous membrane (IOM). These are highlighted in the figure below.

Figure 1: the distal tibiofibular syndesmosis

These injuries are typically associated with high-speed collisions or injuries where the foot is forcefully externally rotated while in a dorsiflexed positon. Other ankle ligaments may be injured concurrently, and it can occur with or without associated fractures.

Why is it important to recognize this injury?

High ankle sprains should be differentiated from the more common collateral ligament ankle sprains, because management and prognosis are different. In the absence of associated fractures, these injuries may be easily missed on imaging and exam, and can be associated with prolonged recovery and chronic pain.

How do you diagnose a high ankle sprain?

History: suspect high ankle sprain if the mechanism is one of forced external rotation of a dorsiflexed foot, or a collision. Pain is usually diffuse, and worse with walking up hills, pivoting, or doing single leg heel raise.

Physical exam:

  • Start with a general ankle exam to rule out other concurrent injuries. This may include an examination of the collateral ligaments, as well as determining the need for imaging with the Ottawa Ankle Rule (http://www.theottawarules.ca/ankle_rules)
  • The following maneuvers are specific to syndesmotic injuries:
    • Crossed leg test (https://youtu.be/Qb-euOa57TE): in sitting position, ask patient to cross their affected leg over the other leg with the distal third of fibular resting on the opposite knee. Apply down-ward pressure over the medial knee of the painful leg. Positive test is reproduction of pain in the ankle.
    • Fibular translation test (https://youtu.be/W3SHqKqkK14): stabilize tibia with one hand, then grasp fibular with other and attempt to translate it anterior or posterior. A painful soft end point with greater than 2 to 3 mm of translation, or increased translation compared to contralateral side is a positive examination.
    • Tibiofibular squeeze test (https://youtu.be/ANgWSz0UoDg): Squeeze the fibular and tibia together using the palms. Pain at syndesmosis is a positive exam.
    • Dorsiflexion external rotation stress test (https://youtu.be/s53uzyUv0bc): Dorsiflex the foot while applying an external rotation force. Pain is a positive test.
    • Stabilization tape test: patient is asked to do dynamic movements including walking, heel and toe walking, single legged heel raise, and standing pivot. Then the ankle is tightly taped in a circumferential fashion just above the ankle joint, and patient is asked to repeat the movements. Positive test is reduction of pain with taping.
    • Direct palpation – tenderness along the anterolateral joint line and proximal compared to typical sprain. Tenderness on palpation may extend proximally along the fibula.

Imaging: Standard lower extremity weight-bearing x-rays (AP and mortise views) may show increased tibiofibular clear space (normal < 6mm), decreased tibiofibular overlap (normal > 6mm on AP view, > 1 mm on mortise view), and increased medial clear space (normal < 4mm). See Figure 2 for reference. Optional stress views (external rotation stress or gravity stress views) may help assess for ankle stability.

Figure 2: Radiographic features of a normal ankle. Image from Orthobullet and altered to include labels (https://www.orthobullets.com/foot-and-ankle/7029/high-ankle-sprain-and-syndesmosis-injury)

CT/MRI are more sensitive and specific but are often not required to make the diagnosis – they should be considered for operative planning or if high suspicion and plain radiographs are normal.

Management:

Without gross instability, high ankle sprains should be treated non-operatively. In contrast to the more common lateral ankle sprains, syndesmotic injuries should be immobilized initially, and patient made non-weight bearing. The immobilization and non-weightbearing phase may be up to 2-3 weeks (or shorter if milder injuries), followed by protected weightbearing in a CAM boot and physiotherapy rehabilitation. High ankle sprains may take over a month to heal.

Surgical indications include unstable ankle on stress views, presence of associated fractures, and failure of conservative therapy.

Summary:

High ankle fractures are syndesmotic injuries that can occur with or without a concurrent fracture and should be suspected when the mechanism is forced external rotation of a dorsiflexed foot or collision. It should be differentiated from a collateral ankle ligament sprain because management and prognosis are different. These injuries should be initially treated with a period of immobility and non-weightbearing, and slowly progress to functional rehabilitation.

Yuhao Shi, MD

Sports and Exercise Medicine Fellow, University of Ottawa

Advisor: Dr. Taryn Taylor, BKIN, MSc, MD, CCFP (SEM), Dip Sport Med

References1,2:

1.           Wake, J. & Martin, K. D. Syndesmosis Injury From Diagnosis to Repair: Physical Examination, Diagnosis, and Arthroscopic-assisted Reduction. J. Am. Acad. Orthop. Surg. 28, 517–527 (2020).

2.           High Ankle Sprain & Syndesmosis Injury – Foot & Ankle – Orthobullets. https://www.orthobullets.com/foot-and-ankle/7029/high-ankle-sprain-and-syndesmosis-injury.

Patellofemoral Pain – A common cause of anterior knee pain

Patellofemoral (PF) pain is a common cause of anterior knee pain in young adults and adolescents. This is described as knee cap pain that is worsened by activities that load onto a flexed knee. These include squatting, stairs, hiking, and running.1,2

The patella acts as a lever which helps extend the knee.1 The patella moves within the trochlear groove of the femur during leg extension and flexion. PF pain is thought to be due to incorrect tracking of the patella.3 More specifically, in PF pain, the patella tracks laterally.

Risk Factors for developing PF pain1

  • Activities including running, squatting, stairs (rapid increase in activities/training)
  • Dynamic valgus (caving in of knees)
  • Female sex (increased Q angle)
  • Foot abnormality (eversion and pes pronatus)
  • Sudden increase in activity level
  • Patellar instability
  • Quadriceps weakness

Diagnosis of this condition is made on a combination of history and physical examination findings. On history, the cardinal feature is that pain around and behind the knee cap is worse during weight-bearing knee flexion activities. Patients may also complain of worsening of their pain after a prolonged period of sitting with the knee flexed (on a plane, in a movie theatre).2

On physical exam, pain with squatting is most sensitive for PF diagnosis.2 Other tests, such as the patellar grind test, apprehension test, and tilt tests, have low diagnostic yields. These do not present with joint swelling, and range of motion is preserved.2

Imaging is not required for the diagnosis of PF pain.1 Radiographs should be obtained in cases where the diagnosis is not clear, or when the patient does not respond to first-line treatment options.2

The treatment of PF pain includes rest, activity modification, and physical therapy. The key is to work on and correct the underlying causes of the pain. This may include avoiding repetitive activities, assessing footwear, and most importantly addressing hip and knee muscular imbalances that cause the knee cap to track incorrectly. Patients should begin with a structured physiotherapy program to help correct imbalances.2 In some cases, foot orthotics can be considered to help with leg alignment and reduce pain in the short term.4 Bracing and taping techniques, while not fully supported by evidence, can help patients during periods of activity by stabilizing the patella.3

Sonam Maghera, MD, BMSc

Sports and Exercise Medicine Fellow, University of Ottawa

Advisor: Dr. Taryn-Lise Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport Med

1.    Gaitonde DY, Ericksen A, Robbins RC. Patellofemoral Pain Syndrome. Am Fam Physician. 2019;99(2):88-94.

2.    Crossley KM, Callaghan MJ, Linschoten R van. Patellofemoral pain. Br J Sports Med. 2016;50(4):247-250.

3.    Jin J, Jones E. Patellofemoral Pain. JAMA. 2018;319(4):418-418.4.         Collins NJ, Barton CJ, Middelkoop M van, et al. 2018 Consensus statement on exercise therapy and physical interventions (orthoses, taping and manual therapy) to treat patellofemoral pain: recommendations from the 5th International Patellofemoral Pain Research Retreat, Gold Coast, Australia, 2017. Br J Sports Med. 2018;52(18):1170-1178.

Multidirectional Instability (MDI) of the Shoulder

What is MDI?

Multidirectional Instability is a condition of the shoulder characterized by recurrent symptomatic subluxation or dislocation of the glenohumeral joint in more than 1 direction. It is more common between the age of 12 and 35, with a slight female predominance. Typically, MDI occurs in the absence of macrotrauma, and is thought to be caused by a combination of ligamentous laxity, presence of redundant joint capsular tissue, and repetitive use.

It is more common in patients with generalized joint laxity, with or without congenital disorders such as Ehlers-Danlos or Marfan syndrome. It may also be associated with repetitive overhead activities such as in swimmers, gymnasts, volleyball players, and weightlifters.

Occasionally MDI can be caused by a major traumatic event, such as in the case of a labral tear. However, in these traumatic cases, the prognosis and treatment considerations are different – the patient usually does well by surgically addressing the structural lesion (e.g. labral tear).

The rest of this article will focus mostly on atraumatic MDI.

Figure source: https://orthoinfo.aaos.org/en/diseases–conditions/chronic-shoulder-instability/

How does MDI present? And how do you diagnose it?

MDI presents on a spectrum ranging from vague shoulder pain without perceived instability to daily occurrences of symptomatic subluxations and frank dislocations with activities. The focus of the history and exam is to identify instability of the shoulder in more than 1 plane.

On history the patient may report some of the following:

  • Sensation of subluxation or dislocation in anterior, inferior, or posterior direction
  • Anterior instability: pain or subjective instability associated with overhead activities where shoulder is abducted and externally rotated. Avoidance of overhead activities.
  • Posterior instability: pain or subjective instability with forward flexion and internal rotation (e.g. pushing open a door)
  • Inferior instability: pain or instability with carrying heavy items.

The physical exam involves the following components:

  • General shoulder exam looking at all pertinent elements such as AC joint, rotator cuffs, scapular motion, joint mobility, biceps function, etc.
  • Assess for generalized ligamentous laxity with the Beighton score (higher score = more ligamentous laxity)
    • Ability to hyperflex elbow or knee > 10 degrees (1 point per joint)
    • Thumb opposition to the ipsilateral forearm (1 point per side)
    • >90 degrees of small finger dorsiflexion (1 point per side)
    • Ability to place palms flat on the ground while bending at the trunk (1 point)
  • Special maneuvers for joint instability
    • Load and shift test (https://www.youtube.com/watch?v=txARar71h5E): stabilize the scapula with one hand. With the other hand, grab the humoral head and attempt to move it anteriorly or posteriorly. Greater translation of the humoral head indicates greater anterior/posterior laxity of the joint.
    • Sulcus sign (https://www.youtube.com/watch?v=vV7u2JtdYWI): with the patient relaxed and in sitting position, pull the arm inferiorly. A feeling of subluxation or appearance of a sulcus or concavity under the acromion is a positive sign for inferior instability
    • Anterior apprehension test (https://www.youtube.com/watch?v=hy7zgoEsbzQ): in supine position, abduct the arm to 90 degrees and add maximal external rotation. Positive test for anterior instability is pain or the fear of subluxation reported by the patient.
      • Relocation test(https://www.youtube.com/watch?v=JkO8nnWFIwM): repeat the apprehension test, but apply pressure at the anterior shoulder (force directed posteriorly). A positive test is reduction of patient’s pain or fear of subluxation.
    • Jerk test (https://www.youtube.com/watch?v=j_qG1MNOws8): in sitting position, place arm into flexion and internal rotation. While applying an axial force to the humerus, bring the arm into horizontal adduction. A positive test for posterior instability is the feeling of posterior subluxation or “clunk” as the humeral head glides over the glenoid rim.

Plain x-rays of the shoulder can be ordered to assess for position of humeral head, and for major glenoid or humeral osseous defects, but are often normal in MDI. MRI of the shoulder allows for assessment of capsuloligamentous structures and evaluation of redundancy of joint capsule. It also helps to rule out other structural lesions such as labral tears that could alter the course of management.

How do you treat MDI?

Most cases of MDI are treated initially with a comprehensive physiotherapy program. The rehabilitation program involves strengthening of rotator cuff and scapular stabilizing exercises to improve stability of the shoulder. An example of a rehabilitation program for MDI is the 6-stage program devised by Watson et al. Most patients respond well to non-surgical therapy.

At least 6 months of therapy should be attempted before considering surgical treatment. Surgical stabilization procedures should be customized for each patient, based on anatomic deficit and direction of symptomatic instability.

In summary, MDI is a condition of shoulder instability in more than one direction, leading to pain and recurrent subluxations. The majority of these patients should be managed with at least 6 months of shoulder rehabilitation program. Refractory cases may be addressed by surgical therapy to stabilize the joint. 

Yuhao Shi, MD

Sports and Exercise Medicine Fellow, University of Ottawa

Advisor: Dr. Taryn Taylor, BKIN, MSc, MD, CCFP (SEM), Dip Sport Med

References1–4:

1.           Warby, S. A., Watson, L., Ford, J. J., Hahne, A. J. & Pizzari, T. Multidirectional instability of the glenohumeral joint: Etiology, classification, assessment, and management. J. Hand Ther. 30, 175–181 (2017).

2.           Longo, U. G. et al. Multidirectional instability of the shoulder: A systematic review. Arthroscopy – Journal of Arthroscopic and Related Surgery vol. 31 2431–2443 (2015).

3.           Best, M. J. & Tanaka, M. J. Multidirectional Instability of the Shoulder: Treatment Options and Considerations. Sports Medicine and Arthroscopy Review vol. 26 113–119 (2018).

4.           Watson, L., Warby, S., Balster, S., Lenssen, R. & Pizzari, T. The treatment of multidirectional instability of the shoulder with a rehabilitation program: Part 1. Shoulder and Elbow vol. 8 271–278 (2016).

Calcific Tendinosis: There are calcium deposits on a shoulder ultrasound, now what?

Calcific tendinosis is a condition that results in calcific depositions in the rotator cuff tendons of the shoulder. Many terms encompass this definition, these include calcific tendinopathy, calcific tendinitis, calcific shoulder periarthritis, calcific tendonitis, or rotator cuff calcification disease.

Contrary to popular belief, calcific tendinosis is not caused by trauma or overuse. While the exact etiology is unknown, there is evidence leading to an association with diabetes and thyroid disorders.1,2 Furthermore, there is some evidence to say those with occupations that promote internal rotation and slight abduction (impingement position) are at higher risk for this condition: desk workers, cashiers, and production line workers.3

The formation of calcium deposits is thought to be due to incorrect healing of the tendon. There are 4 distinct phases of this condition4

  1. Formative phase – formation of calcium deposits in the tissue
  2. Resting phase – deposits remain stable
  3. Resorptive phase – inflammatory reaction occurs, deposits are resorbed, this can cause extreme pain
  4. Post-calcific phase – calcium deposits resorbed, tendon returns back to normal

Presentation and Exam

The onset of pain can be chronic or acute (during the resorptive phase). There is no trauma preceding this pain. On occasion, patients may complain of night pain and decreased range of motion. On exam, patients can present with positive impingement test (Neer’s or Hawkings), painful abduction, and decreased ROM.5

Imaging

Ultrasound is the best and most cost-effective modality to assess calcifications of the rotator cuff. Ultrasound also allows one to assess for tears and dynamic rotator cuff impingement. Calcifications can also be seen on plain radiographs. In those patients whom you are suspicious of a bony pathology, a standard set of shoulder radiographs should be completed (AP, axillary, outlet view).3 MRI is not recommended.

Treatment

Currently, there is no gold standard treatment for calcific tendinosis.

First-line treatment includes conservative measures. These include NSAIDs, physiotherapy, manual therapy, and corticosteroid injections into the subacromial bursa (for those with an acute attack). In those with no improvement in 6 months, further treatment can be considered.3

Second-line options include shockwave therapy and ultrasound-guided needling (barbotage). These treatments are performed by specialized providers. Shockwave therapy attempts to break down calcium deposits and stimulate healing. Ultrasound-guided needling involves attempting to break up and aspirating the calcium deposits. This is complemented with a bursal injection to prevent subsequent bursitis.3 For those who respond to the treatments above, surgery can be considered to remove the calcium deposits.3

In terms of prognosis, 50% of symptomatic patients become pain-free with conservative treatments in 3 months, 20% more pain-free in 1 year. Of the remaining 30%, 20% will improve with barbotage and shockwave therapy. The remaining 10% will likely require surgery.6

Bottom line, most patients will improve with conservative treatment, in those that don’t respond you can consider referral to a provider for shockwave therapy or ultrasound-guided needling (barbotage).

Sonam Maghera, MD, BMSc

Sports and Exercise Medicine Fellow, University of Ottawa

Advisor: Dr. Taryn Taylor, BKin, MSc, MD, CCFP (SEM), Dip Sport Med

References

1.    Harvie P, Pollard TCB, Carr AJ. Calcific tendinitis: natural history and association with endocrine disorders. J Shoulder Elbow Surg. 2007;16(2):169-173.

2.    Mavrikakis ME, Drimis S, Kontoyannis DA, Rasidakis A, Moulopoulou ES, Kontoyannis S. Calcific shoulder periarthritis (tendinitis) in adult onset diabetes mellitus: a controlled study. Ann Rheum Dis. 1989;48(3):211-214.

3.    Sansone V, Maiorano E, Galluzzo A, Pascale V. Calcific tendinopathy of the shoulder: clinical perspectives into the mechanisms, pathogenesis, and treatment. Orthop Res Rev. 2018;10:63-72.

4.    Uhthoff  null, Loehr  null. Calcific Tendinopathy of the Rotator Cuff: Pathogenesis, Diagnosis, and Management. J Am Acad Orthop Surg. 1997;5(4):183-191.

5.    Hawkins RJ, Kennedy JC. Impingement syndrome in athletes. Am J Sports Med. 1980;8(3):151-158.

6.    Noël E. Treatment of calcific tendinitis and adhesive capsulitis of the shoulder. Rev Rhum Engl Ed. 1997;64(11):619-628.

https://www.uptodate.com/contents/calcific-tendinopathy-of-the-shoulder?search=calcific%20tendinosis&source=search_result&selectedTitle=1~26&usage_type=default&display_rank=1

URL for picture above – Up-To-Date

Osteochondritis Dissecans (OCD) of the Knee – Take Home Points for Primary Care Physicians

Osteochondritis dissecans (OCD) is a focal abnormality of subchondral bone that can lead to detachment of a bone fragment and overlying cartilage (See Figure). It typically affects children and adolescents. Most patients are athletes, and risk of OCD is higher in boys than girls.

The most common location for OCD is at the knee, but it can also occur at the elbow (capitellum) or ankle (talus). At the knee, most cases involve the medial femoral condyle, and less often involve the lateral femoral condyle, and the patella.

The pathophysiology is not well understood, but repetitive microtrauma and local vascular insufficiencies are contributing factors.

Why is it important to recognize this condition?

OCD of the knee can be an uncommon cause of knee pain in the pediatric population. If left untreated, it can lead to degeneration of the cartilage and early osteoarthritis.

How does OCD present? And how do you diagnose it?

OCD has 3 main presentations:

  1. Incidental discovery on imaging, patient is asymptomatic
  2. Pain during sports and activities
  3. Continuous pain (this may be insidious onset), swelling, and/or locking of the joint

On exam, joint effusion may be present, and there may be tenderness at the site of OCD (e.g. medial femoral condyle). The Wilson test helps to detect medial condyle lesions – The test is positive if there is pain with internal rotation of tibia during extension of knee between 90 and 30 degrees, and relief of pain when the tibia is rotated laterally.

Differential diagnoses include meniscal tears, symptomatic discoid meniscus, osteochondral fracture, ACL injury, and patellofemoral syndrome.

Plain radiograph is the first step of investigations. AP, lateral, and tunnel views of the knee should be obtained. Findings can range from focal lucency to visibly detached fragment. MRI can be ordered to further characterize the lesion.

What is the prognosis of OCD?

OCD can heal over time or get worse. Factors that are associated with better prognosis include younger age (presence of open physes), smaller size of lesion, and location at the medial femoral condyle. Unhealed lesions, especially those that lead to loose fragments, can progress to osteoarthritis. 

How do you treat OCD?

  1. Asymptomatic patients should be monitored until radiographs are normal.
  2. In general, initially treatment is usually 3-6 months of sports restriction. When adherence to restrictions is poor, a long-leg cast can be used for immobilization in the short term (e.g. 6 weeks).
  3. MRI should be obtained for any patient with persistent pain after initial treatment, in older children (boys > 13, girls > 11) at initial presentation, or atypical location of lesion (i.e. not medial femoral condyle) to further characterize the lesion
  4. Unstable appearing lesions on imaging or persistent pain after 3-6 months of conservative treatment are indications for surgical referral

In summary, OCD is an abnormality of subchondral bone that most commonly affect the medial femoral condyle of the knee. It is an important diagnosis to consider in an active pediatric/adolescent patient presenting with knee pain with or without mechanical symptoms. Diagnosis can be made with plain radiography, and the lesion can be further characterized by MRI. Mainstay of treatment is cessation of sports activities for 3-6 months, and refractive cases require surgery.

Yuhao Shi, MD, Sports and Exercise Medicine Fellow, University of Ottawa

Advisor: Dr. Taryn Taylor, BKIN, MSc, MD, CCFP (SEM), Dip Sport Med

References1,2

1.           Accadbled, F., Vial, J. & Sales de Gauzy, J. Osteochondritis dissecans of the knee. Orthopaedics and Traumatology: Surgery and Research vol. 104 S97–S105 (2018).

2.           Masquijo, J. & Kothari, A. Juvenile osteochondritis dissecans (JOCD) of the knee: Current concepts review. EFORT Open Reviews vol. 4 201–212 (2019).

Take home message from “Arthroscopy Association of Canada: Position Statement on Intra-articular Injections for Knee Osteoarthritis”i

Arthroscopic surgery for knee OA is not recommended. The AAC recommends a 6- to 9-month trial of “appropriate and comprehensive nonoperative treatment” before considering surgical intervention such as arthroplasty. Alternative treatments including intra-articular injections will be discussed below. Although these guidelines discuss injections, it is important to remember that we also have other successful conservative tools to recommend:

  • Weight loss is the first and probably most efficient way to help patients with knee osteoarthritis (OA)
  • Modification of the patient’s activities to low impact such as switching from running to biking or swimming
  • Sleeve braces
  • Unloading braces
  • Strengthening programs for quadriceps, hamstrings, gluteus and abdominal muscles by a physiotherapist
  • Oral NSAIDs in acute flares
  • Topical NSAIDs

These treatments should be optimized, encouraged and followed up on to ensure the patient has attempted all other options before referring to surgery. An active treatment program designed by a physiotherapist with several sessions of exercises & teaching (not only passive therapies such as heat, ice, TENS for the whole session) with an assigned, progressive home exercise program that the patient is compliant to for many weeks.

Corticosteroid injections:

While cortisone injections are commonly used in family medicine practice, there is still some conflicting evidence around its efficacy for pain and function due to small sample sizes and studies of poor methodological quality.

Highlights:

  • More efficient pain relief and function improvement when the OA is less severe (Kellgren-Lawrence grades 1-2).
  • On the other hand, patients with moderate to severe OA and obese patients tend to have limited improvement.
  • The effects of corticosteroids are of a limited duration and commonly last up to 3 months with no benefit over 6 months.

We should also counsel the patient on having a maximum of “3 injections per year”. The rationale behind this recommendation was demonstrated in a study published in the JAMA 2017ii that tried to demonstrate the effects of repeated cortisone injections. The results showed an increase in cartilage volume loss on MRI (but of only 0.11mm) after 2 years of intra-articular triamcinolone injections given every 3 months when compared to saline injections. The cartilage volume loss was of 0.11 mm which has to be taken into consideration in the decision making with the patient as it might be of limited concern in an older patient with severe osteoarthritis, especially with contraindications for arthroplasty.

Recommendation: In patients with mild OA, intra-articular corticosteroid injections provide moderate short-term pain relief and restoration of function, as well as offer a cost-effective treatment option.

Strength of recommendation: Good – A

Hyaluronic acid (HA):

Highlights:

  • HA increases viscosity of synovial fluid, compressive strength of articular cartilage and decreases inflammation
  • Low risk of adverse effects: infection and granulomatous inflammation in 4-13% of injections
  • High-molecular weight (HMW) (> 3000kDa) more efficient than low-molecular weight (LMW) or placebo iii, iv
  • Highly cross-linked more efficient
  • Effect lasting up to 26 weeks but up to a year in some patients
  • Improves pain, function & stiffness in mild to moderate OA

Recommendation:

In patients with mild to moderate knee OA, HMW HA intra-articular knee injection provides pain & function improvement.

Strength of recommendation: Good – A

Platelet-rich plasma (PRP):

Highlights:

  • Plasma with a minimum of 1 million platelets per millilitre
  • Pain & function improvement more significant than placebo (saline) at 6 & 12 months
  • Equal effect to HA at 6 months but superior to HA at 12 months
  • Safe, low risk adverse events (same as placebo)
  • Better efficacy in low grade OA (Kellgren- Lawrence grades 1-2) & younger patients
  • No evidence in severe OA

Recommendation: In mild to moderate knee OA, PRP injection potentially improves pain and functional outcomes up to 1 year after the injection.

PRP composition is affected by time of day & exercise, different PRP preparation systems, concentration of other constituents (WBC, growth factors, etc.). This makes preparations very heterogeneous and therefore harder to interpret, even in meta-analyses attempting to determine the optimal protocol and product. Further high-quality clinical studies are needed.

Strength of recommendation: Cf (f: for/in support of the intervention)

Stem cells:

Highlights:

  • Potential good benefit in lower grades of OA
  • Still very few studies with small sample sizes – more extensive research needed.

Recommendation:

MSC and BMAC injections limited to registered controlled trials only.

Strength of recommendation: Insufficient – I

In early stages of OA, sport medicine physicians prefer starting with weight loss, activity modification, bracing, strengthening exercises/physiotherapy, HA and PRP and then opting for cortisone injections because of the potential long-term effects of cortisone on articular cartilage. Of course, in all cases, treatment options should be personalized to the patient’s needs, severity of pain, functional impact, economic status and other individual variables. Referral to a sport medicine specialist should be considered if assistance is required to guide the patient through the spectrum of management options for knee OA.

Marie-Ève Roy, MD, CCFP
Sports and Exercise Medicine Fellow, University of Ottawa

Advisor: Dr. Taryn Taylor, BKin, MSC, MD, CCFP (SEM), Dip Sport Med


i McAlindon TE, LaValley MP, Harvey WF, et al. Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: a randomized clinical trial. JAMA. 2017; 317(19):1967-1975.

ii Bhandari M, Bannuru RR, Babins EM, et al. Intra-articular hyaluronic acid in the treatment of knee osteoarthritis: a Canadian evidence based perspective. Ther Adv Musculoskelet Dis. 2017;9(9):231-246.

iii Vannabouathong C, Bhandari M, Bedi A, et al. Nonoperative treatments for knee osteoarthritis: an evaluation of treatment characteristics

and the intra-articular placebo effect. A systematic review. JBJS Rev. 2018;6(7).

Steroid Injections in the COVID-19 Era

Does an intra-articular corticosteroid injection lead to systemic steroid absorption? Yes.

There is ample evidence that intra-articular injections of corticosteroids lead to numerous systemic effects. Most common steroids injectates can result in adrenal suppression for over a month. Accordingly, should a patient contract COVID-19 in the month following the injection, the steroid may continue to have a systemic effect.

The evidence for the use of corticosteroids in COVID-19 illness is limited and mixed. At the time of this publication, many societies in Canada and globally, including WHO, recommend against the routine use of steroids for the treatment of viral pneumonias.

The translation of this recommendation to intra-articular injections remains ambiguous. Whether or not the systemic effect of an intra-articular cortisone injection is sufficient to have an impact on the course of illness is completely unclear. Yet, given the uncertainty, prudence would suggest against their use.

If still unconvinced, another consideration could be the impact on the care your patient would receive should he/she suffer from severe illness. Currently, many novel treatment modalities are limited to clinical trials, and a recent corticosteroid injection may impact eligibility for enrolment.

 

What can you do instead?

Go back to basics! An evidence-based physical therapy program for arthritis is a great place to start, even during a pandemic. While many GLA:D programs are closed, information about their exercises can be found at: https://gladcanada.ca/index.php/what-is-glad-canada-2/. Many insurance providers are also moving to cover virtual visits with physiotherapists, allowing patients to receive customized treatment programs.

Alternative pain management modalities include ice, heat, self-massage, and acetaminophen. Of course, reminding patients that while a pandemic does not make it easier, weight management is the cornerstone of happy joints and a healthy body. A reminder that every kilogram of weight loss results in 4 kg off their knee never hurts!

 

Nitai Gelber, MD, CFPC

PGY-3 Sport and Exercise Medicine, University of Ottawa

Advisor: Dr. Taryn Taylor, BKIN, MSc, MD, CCFP (SEM), Dip Sport Med

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

BCCDC. “Unproven Therapies for COVID-19.” 30 Mar. 2020, http://www.bccdc.ca/Health-Professionals-Site/Documents/Guidelines_Unproven_Therapies_COVID-19.pdf.

Fascia, Daniel, et al. “The Safety of Corticosteroid Injections during the COVID-19 Global Pandemic.” AMSIG, 30 Mar. 2020, http://www.amsig.org/recommendations-from-bssr-the-safety-of-corticosteroid-injections-during-the-covid-19-global-pandemic/.

Messier, Stephen P., et al. “Weight Loss Reduces Knee-Joint Loads in Overweight and Obese Older Adults with Knee Osteoarthritis.” Arthritis & Rheumatism, vol. 52, no. 7, 2005, pp. 2026–2032., doi:10.1002/art.21139.

Russell, Beth, et al. “COVID-19 and Treatment with NSAIDs and Corticosteroids: Should We Be Limiting Their Use in the Clinical Setting?” Ecancermedicalscience, vol. 14, 2020, doi:10.3332/ecancer.2020.1023.

WHO. “Clinical Management of Severe Acute Respiratory Infection (SARI) When COVID-19 Disease Is Suspected.” 13 Mar. 2020, http://www.who.int/docs/default-source/coronaviruse/clinical-management-of-novel-cov.pdf.

Lower limb stress fractures in sport: Optimizing management and outcome

Stress fractures are common injuries in athletes and account for 10% of all sport injuries.  Ninety percent of stress fractures are located in the lower extremities. The risk factors related to stress fractures consist of the following: a history of past stress fractures, female sex, training regimen, footwear, training surface, and type of sport with repetitive loading (such as running and jumping). Non-steroidal anti-inflammatory drugs should be avoided in all fractures as they may inhibit callus formation and slow down the initial healing process.

In the management of stress fractures, 7 aspects should be considered:

  • Is the fracture low or high risk?
  • What is the optimal imaging modality?
  • Conservative versus surgical treatment?
  • What technique is chosen if surgical?
  • What optimal rehabilitation schedule if conservative treatment?
  • How fast can sport be resumed?
  • What preventive program is available for this type of fracture?

In all stress fractures, radiographs are the first-line modality and may reveal linear sclerosis and periosteal reaction prior to the development of a frank fracture. In most stress fractures, the radiographs are negative although clinical symptoms are present. When a high-risk stress fracture is considered and radiographs are negative, a bone scan, CT scan or MRI is recommended. MRI is highly sensitive with findings ranging from periosteal edema of bone marrow to intracortical signal abnormality.

Conservative management ranging from non-weightbearing with a cast or Aircast with crutches to limited weightbearing crutch-assisted without pain is usually the optimal treatment when possible, even in high risk fractures.

High risk stress fractures;

A stress fracture is considered high risk because it is located either on the tension side of the bone or in an area of limited vascularity. Therefore, they are at increased risk of fracture propagation, displacement, non-union or delayed union. High risk stress fractures should be referred to orthopedic surgery with immediate cessation of activity as they might need surgical treatment. Those include distal anterior tibial diaphysis, fifth metatarsal base, medial malleolus, lateral femoral neck, tarsal navicular and great toe sesamoid. These fractures require specialized imaging to define and quantify the injury. The location of injury and response to initial conservative treatment will determine whether surgical management is needed.

High risk sport related stress fractures include the following:

 Anterior tibial diaphysis:

In 85% of cases, the radiographs are negative although clinical symptoms are present which should accelerate the request for a bone scan, CT or MRI. Treatment protocols consist of conservative management for 3 to 6 months with crutch-assisted weightbearing until resolution of pain in lower grade injuries and of casting in higher grades of injuries. In case of failure of conservative treatment, then a surgical intervention is recommended. The return times to sports for such injury is usually 7 months for both conservative and surgical management. However, the return to sports rates differed with 71% for conservative management and 96% for surgical management.

An exception is made when a complete fracture line is seen with both cortices involved. In this case, the stress fracture should be managed as an acute fracture. If the fracture is undisplaced, conservative management is recommended. If the fracture is displaced, a surgical intervention with an intra-medullary nail is required. The return times for these injuries then increases to 11.5 months for conservative management and 7 months for surgical management. The return rates remain similar with 67% for conservative and 100% for surgical management. For conservative management, recommended rehabilitation techniques consist of activity cessation, with avoidance of heavy loading of the tibia, limited weightbearing with crutches for 3 to 6 months. For surgical management, rehabilitation involves a progressive weight-bearing program supervised by a physiotherapist starting the first week following surgery with return to full loading activities between 6 and 8 weeks after surgery.

Fifth metatarsal base:

These stress fractures present on radiographs as a sclerotic or radiolucent line at the proximal aspect of the fifth metatarsal. These changes can be absent on radiographs in up to 69% of patients for this type of fracture. Again, MRI is the second line imaging. CT can be used to assess if there is fracture union after conservative treatment. Treatment of these fractures depends on the radiologic “Torg” classification. Conservative treatment is now often favored except in high level athletes and in high repetitive loading sports (running, jumping) where surgery is considered first line. If there is delayed union (Torg 2) or non-union (Torg 3), surgery is also recommended.

Medial malleolus:

Radiographs can be negative in 55% of cases. For undisplaced fractures, they can be treated conservatively in low level athletes although a good evaluation has to be done as these fractures tend to contribute to long term ankle instability. These injuries must be followed by strengthening, range of motion and proprioception training with a physiotherapist to prevent ankle instability.

Lateral (tension side) femoral neck:

Theses stress fractures occur most commonly in marathon and long distance runners. They are not seen on radiographs in up to 80% of cases. This stress fracture is treated with urgent surgical fixation to prevent fracture displacement and associated risk of avascular necrosis (AVN) of the femoral head. A minimum of 2 years clinical and radiographic follow-up should be done to ensure that delayed post-treatment AVN does not occur.

Navicular:

These stress fractures present most commonly in sprint runners. In high level athletes, surgical management may result in faster return to sport time but some randomized control studies are still needed to confirm this.

Sesamoids (great toe):

These stress fractures occur most commonly in sports such as dancing, gymnastics and sprinting; all involving forced dorsiflexion of the great toe. Medial sesamoid fracture is more common than lateral sesamoid as load occurs on the medial aspect of the toe with gait. Conservative treatment is the first line approach. However, if the patient remains symptomatic after 3 to 6 months, surgery should be considered because of a high rate of delayed union, non-union and fragmentation.

Low risk stress fractures:

Low risk fractures are treated with rest and exercise limitation because of the low risk of fracture propagation, non-union or delayed union. These include posteromedial tibial diaphysis, metatarsal shafts, distal fibula, medial femoral neck, femoral shaft and calcaneus.

In the majority of low risk stress fractures, a bone scan or radiographs are sufficient and the x-ray can be repeated instead of ordering a CT scan or MRI. In the case of medial femoral neck, femoral shaft or calcaneus fracture suspicion, an MRI should be requested because of the possibility of surgical management or to exclude other diagnoses.

Medial femoral neck:

If a fracture line is more than 50% of the femoral neck width or is displaced, a surgery is required to stabilize the fracture.

Femoral shaft:

Displaced fractures, delayed union and non-union require surgical consultation.

Calcaneus:

MRI can help to eliminate differential diagnoses such as plantar fasciitis, Achilles tendinosis and retrocalcaneal bursitis. These stress fractures are also difficult to detect on radiographs and may require surgical intervention if there is subtle displacement.

Metatarsal shafts fractures:

Among metatarsals, the second is the most common affected, followed by the third and fourth metatarsals. These fractures are usually treated conservatively with activity limitation for 6 to 8 weeks with an Aircast boot, short leg cast or fore-foot offloading shoe. Progressive return to exercise as pain allows can then be started.

In conclusion, it is important to remember that negative plain radiographic findings should not be considered alone but in conjunction with clinical findings. In the case of negative imaging with positive clinical findings, if there is a suspicion of high-risk stress fracture, additional imaging (bone scan, CT, or MRI) must be requested and conservative treatment implemented immediately for optimal treatment. If a low risk stress fracture is suspected, additional bone scan and serial plain radiographs are sufficient with conservative treatment, except in the case of femoral fractures suspicion.

In all stress fractures, independent of whether management is conservative or surgical, full level sport should not be started until there is clear evidence of clinical and radiological union and pain free ambulation.

Marie-Ève Roy, MD, CCFP
Sports and Exercise Medicine Fellow, University of Ottawa

Advisor: Dr. Taryn Taylor, BKin, MSC, MD, CCFP (SEM), Dip Sport Med

 

References:

Robertson GA, Wood AM. Lower limb stress fractures in sport: Optimising their management and outcome. World J Orthop. 2017 Mar 18;8(3):242-255.

Saunier J, Chapurlat R. Stress fracture in athletes. Joint Bone Spine. 2018

May;85(3):307-310.

Matcuk GR Jr, Mahanty SR, Skalski MR, Patel DB, White EA, Gottsegen CJ. Stress fractures: pathophysiology, clinical presentation, imaging features, and treatment options. Emerg Radiol. 2016 Aug;23(4):365-75