CPS Peds Sports and exercise medicine section

Question 1

What 3 ligaments provide stability to the ankle laterally?

-what ligament provides stability to the ankle medially?

Answer 1

1. Anterior talofibular ligament (ATFL) 2. Calcaneofibular ligament (CFL) 3. Posterior taloficular ligament (PTFL)

Medially: -deltoid ligament

Question 2

What is the most commonly injured ankle ligament? -mechanism of injury?

Answer 2

Anterior talofibular ligament -inversion of plantarflexed foot

Question 3

What is a “high ankle sprain”?

Answer 3

Interruption of the syndesmotic ligament between the tibia and fibula

Question 4

What injuries must be excluded before diagnosing a child with an ankle sprain? (4)

Answer 4

1. Proximal fibular fracture
2. SH I of fibular epiphysis (the above way more common than sprains in young children)
3. Fracture of base of 5th metatarsal
4. High ankle sprain - Interruption of the syndesmotic ligament between the tibia and fibula

Question 5

What are the Ottawa ankle rules?

Answer 5

***Use in children > 10 yo

An ankle xray series is only necessary if there is pain in the malleolar zone AND any of the following:

1. bone tenderness at the posterior edge or tip of the lateral malleolus
2. bone tenderness at the posterior edge or tip of the medial malleolus
3. inability to weight bear both immediately and in the ED

Question 6

What are the Ottawa Foot rules?

Answer 6

***Use in children > 10 yo

Foot xray series only necessary if there is pain in the midfoot zone AND any of the following:

1. Bone tenderness at base of 5th metatarsal
2. Bone tenderness at navicular bone
3. Inability to weight bear both immediately and in the ED

Question 7

What is the management of an ankle sprain?

Answer 7

PRICE

1. Protection: no evidence to support a positive effect of immobilization (can cause decrease in strength) -can do functional bracing with early mobilization -can use ankle stirrups acutely -when returning to sport, can use a functional brace for the 1st 3-6 months to protect the ankle from further injury while ligaments are healing
2. Ice: decreases time to recovery by 30-60%; 15 mins at a time, OD-TID for first 2 days
3. Compression and elevation: little evidence to support but expert opinion supports.
4. NSAIDs
5. Rehab: physiotherapy!

Question 8

When can an athlete return to play after an ankle sprain?

Answer 8

1. Step-wise fashion when ROM, strength and proprioception have returned to normal and pain has resolved (1-6 wks time)
2. -continue physio until athlete returns fully to play
3. -wear a brace to protect the ankle 3-6 months following returning to sport

Question 9

What is the difference between low back pain in youth vs. adults in etiology?

Answer 9

• Youth = tend to result from structural injuries (ie. spondylolysis)
• Adults = tend to result from disc pathology, muscular strain

Question 10

What is the most common cause of lower back pain in children and adolescents? -complications? (4)

Answer 10

Spondylolysis -stress fracture of the pars interarticularis caused by repetitive spinal extension and rotation -usually occur in lumbar vertebrae, especially at L5

-see in teens commonly because they have incomplete ossification of the pars interarticularis, predisposing to spondylolysis

Question 11

What type of movement worses spondylolysis pain?

• treatment for spondylolysis?
• return to play guidelines? -prognosis?

Answer 11

Extension of back

Treatment:

1. Physiotherapy: abdominal strengthening, hip flexor and hamstring stretches, antilordotic exercises
2. Rest
3. +/- brace to limit spinal extension x 4-8 weeks or until pain-free

-Return to play:

gradually increasing activity ..

1. 4-8 weeks with a brace
2. 3-6 months without a brace
   - Prognosis: most athletes with spondylolysis return to full activities without a brace and without pain within 6 months if treatment guidelines followed

Question 12

Why are adolescents more predisposed to back injuries? (4)

Answer 12

1. Muscle imbalance
2. Inflexibility
3. Structural differences of the spine -growth cartilage, secondary ossification centers (susceptible to compression, distraction and torsion injury)
4. Improper training

****due to growth spurts = muscles and ligaments cannot keep pace with bone growth

Question 13

Which 3 sports increase the risk of spondylolysis?

Answer 13

1. Dance
2. Figure skating
3. Gymnastics -require repetitive spinal extension and rotation

Question 14

What are 3 key features on history suggesting spondylolysis? -3 key features on physical exam?

Answer 14

History:

1. Pain worsened by extension
2. Insidious onset
3. Pain with impact activities (running, jumping)

Physical exam:

1. Hamstring tightness (as seen in our patient who was a water polo player seen with Dr. Moroz) = flex knee, flex hip and look at popliteal angle! If decreased, hamstrings are tight
2. Hyperlordosis
3. Paraspinal muscle spasm

Question 15

What are 3 investigations you can perform for diagnosis of spondylolysis?

Answer 15

1. AP and lateral spine xrays = fracture at neck of the scottie dog
2. CT bone scan: shows increased uptake in pars interarticularis
3. CT scan

Question 16

Spondylolysis What are the complications of Spondylolysis?

Answer 16

If untreated: complications

1. Spondylolisthesis: vertebrae slipping out of place
2. Spinal stenosis = narrow of spinal canal pinching spinal cord 3. Cauda equina syndrome = due to compression by intervertebral disc
3. Radiculopathy

Question 17

What is posterior element overuse syndrome?

• clinical features?
• treatment?
• prognosis?
• return to play?

Answer 17

aka mechanical/muscular back pain = constellation of conditions involving the posterior spine (muscle tendon units, ligaments, facet joints)

-Clinical features?

1. -present with insidious onset of extension-related back pain
2. -focal tenderness of lumbar spine and paraspinal muscles
3. -all investigations are negative

• treatment:
  1. Ice 2. NSAIDs 3. Pain-free activity is allowed
  4. Physiotherapy: antilordotic exercises, abdominal strengthening, hamstring stretches
  5. Antilordotic bracing may be helpful
• prognosis: most athletes can resume full activity without pain within 4-8 wks

Question 18

How do the following present in terms of onset (ie. insidious vs. acute)?

• spondylolysis
• posterior element overuse
• vertebral avulsion fracture
• disc herniation

Answer 18

• Spondylolysis = insidious
• Posterior element overuse = insidious
• vertebral avulsion fracture = acute
• disc herniation = usually acute (sometimes chronic)

Question 19

What is a vertebral body apophyseal avultion fracture?

• cause?
• seen most commonly in which sports?

Answer 19

Avulsion fracture of ring apophysis of the vertebral body

• caused by repetitive spinal flexion and extension
• fracture can posteriorly displace into the spinal canal along with the intervertebral disc
• sports: volleyball, gymnastics, weight lifting (lots of flexion)

Question 20

What type of movement induces pain in the following (ie. flexion vs. extension)?

• spondylolysis
• posterior element overuse
• vertebral avulsion fracture
• disc herniation

Answer 20

• spondylolysis: extension
• posterior element overuse: extension
• vertebral avulsion fracture: flexion
• disc herniation: flexion

Question 21

What are clinical features of vertebral body apophyseal avulsion fracture? (4)

-finding on imaging?

Answer 21

1. Acute onset
2. Flexion-related lumbar pain
3. No neuro symptoms
4. On exam, spinal flexion and extension limitation, paraspinal muscle spasm
   - On
5. -lateral lumbar spine xrays: ossified fragment in the canal
6. -on CT = displaced apophyseal fracfture

Question 22

What is the management of vertebral body apophyseal avulsion fracture?

• return to play?
• indications for OR? (2)

Answer 22

1. Rest with no sports x 3-6 months
2. Heat
3. NSAIDs
   - return to play after 3-6 months if pain free

-indications for OR for surgical incision of fragment: NEUROLOGICAL ABNORMALITIES!

1. Lower extremity weakness
2. Loss of bladder/bowel control

Question 23

What are symptoms of disc herniation? (4)

• signs on physical exam? (3)
• test of choice for initial diagnosis?
• test of choice for progression or refractory symptoms?

Answer 23

1. Acute onset
2. Flexion-related pain
3. Associated with back muscle spasms, hamstring tightness, buttock pain (sometimes)
4. Occasional radicular symptoms (muscle weakness, paresthesias)

Exam findings:

1. Positive straight leg raise

2. Decreased reflexes/strength of lower extremities
3. Decreased lumbar flexion

-test of choice for initial diagnosis:

lumbar xrays to rule out fractures or tumors but if normal and have clinical signs of herniation, then your diagnosis is made.

-test of choice if refractory or progressive symptoms: MRI to look for extent of herniation, nerve root impingement

Question 24

What is the management of disc herniation?

-indications for surgical intervention? (3)

Answer 24

1. NSAIDs 2. Physiotherapy
2. Rest x 3-6 months, then can return to play

-indications for surgery:

1. Cauda equina syndrome (leg paralysis, loss of bowel/bladder function)
2. Refractory pain
3. Progressive neurological deficit

Question 25

What are red flag symptoms for lower back pain? (5..in 3 categories)

Answer 25

1. Fever, Weight loss & Malaise
2. Night pain
3. Neurological abnormalities

Question 26

Name 3 techniques in which to prevent lower back injury in young athletes?

Answer 26

1. Reduce training during time of rapid growth
2. Emphasize proper techniques
3. Core-strengthening exercises, hamstring and hip flexor stretches

Question 27

What are quantitative changes in the immune system caused by exercise?

-what is the immunological open window?

Answer 27

1. Increase in neutrophils and lymphocytes during exercise but then lymphocyte counts diminish with cortisol levels rising with continued exercise
2. Decreased CD4 cells compared to CD8 cells = infection suceptibility
3. Decreased salivary IgA concentration

***immunological open window: brief period of immunosuppression after intense exercise

Question 28

What is the J curve in the relationship between the amount of exercise and incidence of infections?

Answer 28

J curve

People who exercise at moderate level have enhanced immune function and may experience fewer illnesses and shorter duration of illness compared to those who don’t exercise at all

-however, elite athletes training at high levels may be at greater risk of infection

Question 29

Should an athlete continue training if they have an infection causing a fever?

Answer 29

No!

1. Fever increases insensible fluid losses = increases risk of dehydration
2. Fever affects body’s ability to regulate body temp = greater risk of heat stroke
3. Decreases muscle strength and endurance

_***Exercising during illness can prolong the illness_

Question 30

An athlete presents to you with an infection. How do you decide whether you can let them return to play or not?

Answer 30

Neck check rule = if symptoms are confined to above neck (rhinorrhea, congestion, sore throat), can continue to participate as long as they feel able to

• exercise at mild-moderate intensity x 10-15 minutes; if symptoms worsen, stop and rest. If no worsening, then can continue to participate
• if there are SYSTEMIC symptoms (fever, myalgias, diarrhea, tachycardia), no exercise x 7-14 d until symptoms resolve
• once recovered, ease back into sports gradually

****Also need to think about the athlete infecting their team mates

Question 31

How reliable is a physical exam in detecting splenomegaly in infectious mononucleosis?

Answer 31

Not reliable!!

-thus, need to assume that any patient with infectious mononucleosis has splenomegaly and counsel appropriately

Question 32

What is the risk of splenic rupture in IM and when are patients at highest risk?

• how long should athletes be kept out of sports if diagnosis of IM?
• what are the criteria to returning to play?

Answer 32

Risk of splenic rupture in IM 0.1-0.5%

• Risk of splenic rupture -highest in first 3 weeks of illness -splenic rupture after that is very rare. -exclude from sports for MINIMUM of 3 weeks beginning from onset of symptoms
• after 3 weeks, may resume low impact noncontact training at 50% of preillness level AS LONG AS:
  1. Resolution of symptoms (fever, malaise, lymphadenopathy, fatigue, pharyngitis)
  2. Normalization of all lab markers
  3. Resolution of splenomegaly ON ULTRASOUND ideally
  4. Resolution of any complications (ie. hepatitis, enlarged tonsils, etc)
• if improved in first week of graded return to activity with no symptom relapse, then can be cleared to return to sports fully

Question 33

What are ways athletes can reduce their risk of infection? (9)

Answer 33

1. Update vaccines
2. Reduce life stressors
3. Do not share water bottles or towels
4. Avoid contact with people who are sick
5. Well balanced diet
6. Get adequate sleep
7. Avoid overtraining and fatigue
8. Allow adequate recovery time following intense exercise
9. Wash hands

Question 34

What sport activities is appropriate for children 2-5 years of age?

Answer 34

Limited fundamental sports and balance skills with short attention spans

• focus on emphasizing fundamental skills and PLAY rather than competition
• should definitely avoid competition
• running, tumbling, throwing, catching, riding tricycle

Question 35

What sport activities are appropriate for children 6-9 yo?

Answer 35

Starting to acquire mature fundamental motor skills, still have short attention spans

• rules should be flexible, instruction times short, minimal competition is best
• activities: entry level soccer, baseball, swimming, running, skating, gymnastics, dance, racquet sports, etc.

Question 36

What sport activities are appropriate for children 10-12 yo?

Answer 36

Boys and girls are able to compete evenly since girls are temporarily taller and heavier due to onset of puberty

• complex motor skills, better attention spans
• focus on skill development with emphasis on strategy and tactics
• activities: entry level football, basketball, ice hockey

Question 37

What sport activities are appropriate for children 13-15 yo?

Answer 37

Increased muscle mass, strength, cardioresp endurance BUT temporary decrease in coordination, balance and flexibility -any sports are appropriate based on their body type