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Sports Medicine

Sports Medicine

Liaison: Dr. David Kilgore

Updated: January 12, 2005

Introduction

The U.S. population is increasingly interested in sports and exercise related activities. There is heightened interest in active participation, often beginning in childhood and extending to the geriatric age range. Primary care physicians initially see the majority of all exercise and sport injuries. As a result, family physicians are called upon to treat a multitude of musculoskeletal complaints, and offer guidance on fitness evaluation, exercise prescriptions, nutrition, and injury prevention. Additionally, family physicians are often called upon to function as team physicians in communities where they practice. Congruent with the basic philosophy of Family Medicine, with its emphasis on comprehensive and continuous care, the family physician is the ideal health professional to assess and guide patients in this area.

Specific training is needed to provide competent musculoskeletal care to the growing numbers of our active population. Starting with the basics of exercise physiology, nutrition and issues of safety, the knowledge base extends to pre-participation assessments (sports physicals), care of injuries and their subsequent rehabilitation. Laying a groundwork of cognitive, behavioral and procedural skills following the recommendations of the AAFP core educational guidelines, it is hoped the family practice resident will capably address and manage sports and exercise related issues in their patient’s lives and know how to build on this framework after training.

Goals

Basic Knowledge

  1. Introduce the resident to the concept of sports medicine as a multidisciplinary field, in which the family physician has a uniquely important place and perspective to offer.

  2. Become familiar with the basic science of sports medicine, including basic exercise physiology, biomechanics of common sports and nutrition guidelines.

  3. Appreciate the common psychosocial problems relevant to exercise and competitive sports.

  4. Be aware of the duties and responsibilities involved in the role of the team physician.

Injury Management

  1. Develop skills in the recognition, diagnosis and treatment of the most common types of acute sports injuries and overuse syndromes, both traumatic as well as environmental.

  2. Gain proficiency in specific procedural skills relevant to prevention, treatment, and diagnosis of common sports injuries.

  3. Understand the components of effective rehabilitation after injury.

Health Promotion / Injury Prevention

  1. Attain proficiency in pre-participation evaluation and assessment for various age groups for common sports and recreational activities.

  2. Be aware of the special needs of particular age groups and diseases that impact safe participation.

  3. Learn different approaches to injury prevention through knowledge of common injury patterns, proper sports training and appropriate use of equipment.

  4. Be proactive in health promotion regarding guidance and education in exercise participation for patients and their family.

Objectives

Basic Knowledge

Describe the following basic components of exercise physiology:

Be capable of providing relevant nutritional advice and information, including:

Psychosocial Factors

Discuss strategies to facilitate exercise participation. List common psychological adjustments to injuries in athletes.

Health Promotion and Injury Prevention

Pre-participation evaluations

  1. Explain the purpose of the pre-participation evaluation for organized sports and contrast it with routine physical examinations.

  2. State the disqualifying conditions for participation in contact and non-contact sports that should be identified during a pre-participation exam.

  3. List collision, contact and non-contact sports.

  4. Define essential components of the P.P.E. history and physical exam, which identify high-risk conditions.

  5. Demonstrate a directed pre-participation physical exam.

Pre-participation Physicals Lecture

Special Needs Groups

Chronic Disease

Discuss the risks and benefits and any considerations for exercise modifications for individuals with:

Exercise in Children

Describe the role of the family physician in promoting exercise in children, including the benefits and drawbacks of participation in organized sports.

Describe the following common bone injuries and traumatic disorders distinct to the immature skeleton of the pediatric athlete:

Exercise in the Elderly

  1. Describe age related changes in the C-V, respiratory, and musculoskeletal systems that affect exercise response.

  2. List common injury sites in the older athlete and ways to prevent these injuries.

Female Athletes

  1. Review common exercise modifications for pregnancy.

  2. Discuss the main issues surrounding the female athlete triad: amenorrhea, eating disorders, and osteoporosis.

Injury Prevention

List common injuries or joints/body areas at risk for the following sports:

Explain the term overuse syndrome, and describe the basic principles of treatment and prevention.

List indications for protective taping or bracing of joints, then demonstrate proper taping or bracing of the:

Fitness

  1. Discuss the basic principles guiding training to improve C-V fitness.

  2. Explain the importance of warming up, cooling down, and stretching for an exercise program. Describe or demonstrate common techniques to stretch the major muscle groups.

  3. Describe common methods of strength training and the appropriate frequency in an exercise program.

  4. Competently perform exercise treadmill evaluations and use the results to make recommendations for an exercise program.

Injury Rehabilitation

Discuss basic approaches to the rehabilitation of the following injured areas, identify the usual time course for successful rehab and indicate when further consultation would be indicated.

Discuss basic differences in strengthening maneuvers between isometric, isotonic and isokinetic exercises and reasons to employ each of them. Describe the differences between concentric and eccentric muscle contraction and which is better for muscle strengthening.

Injuries

Discuss conditions that place an individual at risk for overuse injuries.

Describe the diagnosis, management and prevention of the following overuse injuries:

For the common closed fractures listed below, the resident will:

Describe common presenting signs, symptoms, and physical exam findings.

List appropriate imaging studies and results.

List referral indications and review potential complications of the fracture.

Outline a management strategy.

For the following dislocations, list physical exam findings, x-ray views to request and the results, relocation maneuvers and the subsequent management:

Compare and contrast spondylolisthesis and spondylolysis, reviewing relevant anatomy, radiology findings and relevant signs and symptoms. What sports are at highest risk of overuse spondylisthesis problems?

For the soft tissue injuries listed below, the resident will complete the following:

Describe common presenting signs, symptoms, and physical exam findings.

List appropriate imaging studies and results.

List referral indications and review potential complications.

Outline a management strategy.

Injury Management Skills

Perform a thorough exam of the joints, demonstrating maneuvers to identify range of motion, joint stability, surrounding muscle strength, soft tissue damage, neurovascular integrity and signs of a fracture or dislocation.

Demonstrate correct technique for application of the following casts or splints, using both plaster and fiberglass material:

Demonstrate or describe the appropriate technique for reduction of the following fractures or joint dislocations:

Perform the following soft tissue or joint injections, listing indications, potential complications and supplies needed:

Demonstrate proper technique for performing arthrocentesis of the knee, elbow and wrist.

Demonstrate the proper technique for performing the following nerve or regional blocks:

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Overview and Scheduling

This rotation includes several different types of experiences designed to fulfill the goals and objectives for the sports medicine curriculum. Although some of the rotation will be at Madigan Army Medical Center, Department of Family Practice, the curriculum includes some other important experiences as well. Sample Schedule

Madigan

You will spend several half-days in the sports medicine injury clinics of Dr. Joe Dziados (pronounced “Jaw-dose”), a sports medicine, fellowship trained family physician at MAMC. Go to the Madigan instructions. If you will not be starting on the prescheduled date, please call the GME office at 968-1511.

Other possible fill in options at Madigan – check with Dr. Dziados:

PMR clinic: Drs. Jose Figueroa, Erik Dahl – located first floor across from the ER

Podiatry and Foot Clinic: Drs. Jeff Zimmerman and Vickie Driver – located in ortho clinic

UPS

One half-day (Tuesday afternoons) are spent in the training room at University of Puget Sound (corner of North 11th Street and North Union) observing their team physician Mike Bateman, M.D. (a former TFM grad) and the head athletic trainer, Zeke Schuldt, treat college student athletic injuries and illness. The afternoon starts at 2:30 pm with Dr. Bateman arriving closer to 5pm, and runs to about 7pm. You go to the UPS field house located near the SE corner of North 11th St and North Union, and enter at the SW side of the building by the tennis pavilion, go down the steps into the building, then go up the first left hallway. The training room is first door on your left. All the AT staff knows you are coming, so just go in and introduce yourself and have fun.

UPS clinic is located on the corner of North 11th Street and North Union. Zeke Schuldt, Head AT. Phone: 879-3441

Community Orthopedic/Sports Medicine Office

You will also spend several half days with Greg Popich M.D., Jeff Nacht M.D. and Fred Thompson, M.D. All are orthopedic sports medicine physicians.

Pacific Sports Medicine is located at 3315 S. 23rd St. #200 (near Target, just down from Allenmore). Phone: 572-8939

Pre-Participation Sports Physical Exams

Each R3 must participate in at least one group sports participation screening exam, usually done at our local middle school, Jason Lee, at the corner of 6th Ave and Division.

Your PPE exam date will be scheduled for a weekday morning from 8-9 am by the sports medicine faculty liaison sometime during the year.

Team Physician Shadowing

Residents and fellows have some great opportunities to learn important skills of being a team and sporting event medical volunteer provider by shadowing physicians and certified athletic trainers. This is valuable experience that is only obtainable by making some effort to go to at least a couple of events and watching and participating with treatment of acute injuries and illness. Our area is blessed by having the following opportunities – please take advantage of them:

  1. University of Puget Sound – nearby in the north end – team physician is Mike Bateman, M.D., a TFM grad! He attends all home football games, and others as he is able, and has specifically said he would welcome having a resident with him at any time for a game. A great athletic training team covers all of their sporting events. The training team is quite experienced with acute injury management and return to play guidelines, etc. Click here for information about the dates and times of their various home sporting events.

For further information you can also contact Mike Bateman at 552-4905, or the head AT at UPS, Zeke Schuldt, at 879-3441

  1. Apple PT is the official team event coverage for WIAA events at the Tacoma Dome, and all of you are officially invited to attend these events and help their AT’s and PT’s with coverage. They also always have EMT’s at every event. Example sports are the Football gridiron classics in the fall, wrestling in late fall and early winter, and basketball in early spring. Contact is: Bonnie Gutierrez, PT, ATC, 572-8684 or bonnie@applept.com

Required Reading

AAFP Monograph 222: Sports Medicine AAFP Monographs 160, 161, 169: Sports Medicine I, II and III Post-tests at the end of each monograph Pick up these monographs from Kary Trumble at the start of your rotation.

Optional Reading

Sports medicine syllabus - articles on injury management, nutrition, training, and team physician for reference.

Primary Care Orthopedics Videotape series - in my office.

Recommended for personal library:

Fracture Management for Primary Care, 2nd edition P.Eiff, et al. – this is strongly recommended for all residents – the best fracture book made for primary care. Sports Medicine for the Primary Care Physician, R. Birrer Sports Medicine: Principles of Primary Care, Scuderi, McCann, Bruno Evaluation of Orthopedic and Athletic Injuries, Chad Starkey ACSM’s Guidelines for the Team Physician, R. Cantu ACSM’s Guidelines for Exercise Testing and Prescription

Recommended Web sites:

Physician and Sports Medicine Journal Home Page

AAFP’s website for a variety of guidelines and consensus statements from AAFP, and information on preparation for role as team physician

National information on steroid abuse in sports

American Academy of Sports Medicine for all kinds of links to sports medicine information

CDC site on brain injury with links to specific guidelines for sports medicine management of concussions

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Madigan Information

First Day

The first time you enter Madigan, you will need to obtain a temporary gate pass. Please follow the instructions below carefully, as badges are not issued at the hospital.

If possible, it would be helpful to take care of the bureaucratic red tape stuff a day or two before your rotation so you do not have to waste time during this gem standing in line for badges, etc.

Take I-5 south to exit 120 Fort Lewis (one exit past the Madigan exit) Turn left from the off ramp, and proceed to the main gate to obtain a temporary vehicle pass. You will need to present a driver’s license, car insurance policy #, make/model and license plate # of your car.

Then get back on the freeway, going north again, back to exit 122 - Madigan Hospital. Follow signs to the hospital, and park in any staff parking lots (see map). Do not park in the outpatient parking lot for patients.

Enter the Medical Mall, turn right, following signs to the family practice clinic, and ask for Dr. Joe Dziados

During the morning of your first day, go to the Graduate Medical Education (GME) office located in the Nursing Tower to pick up your badge card. Their hours are Monday through Friday 8:00 – 4:30 pm. You will then take the badge card plus the same car information to the Provost Marshall Office on the second floor of the Medical Mall (the GME staff will give you directions) to get your month car pass and badge.

Madigan Photo I.D.’s are taken at the Provost Marshall’s office on Mondays, Wednesdays and Fridays from 9 a.m. – 11:30 a.m. The whole checking in process can take up to 2 hours on this first day, but then you’re set for the rotation.

Subsequent Days

Once you have your month parking pass, you can exit directly at the Madigan Exit #122, and go directly to the hospital.

Introductory Letter for Gate Clearance First Day

This is your “magic ticket” to the front gate at Madigan for your first day – be sure to show it to the guard.

Ask if any questions, and enjoy!

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Team Physician Role & Athletics

Liason: Dr. David Kilgore

Updated: September 21, 2004

Team Physician Role

  1. List the responsibilities assumed in the role of team physician.

  2. Discuss return to play guidelines for:

    a. Knee injury

    b. Ankle injury

    c. Concussion

  3. Specify steps to take in case of suspected:

  4. C-spine injury

  5. Concussion

  6. Review first-aid equipment needed at field side.

  7. List one resource available to advise athletes regarding allowed and banned drugs and medications for competition.

  8. Indicate safe temperature ranges for competition and summarize strategies for minimizing risks of heat injury.

  9. Discuss liability issues involved in the role of team physician and what circumstances require additional malpractice coverage.

Athletic Trainer Role

  1. Describe common protective strapping / taping methods for:

  2. Ankle

  3. Shoulder

  4. Knee

  5. Wrist

  6. Fingers

  7. Discuss how to assess the proper fit of common protective equipment such as football helmets and shoulder pads.

  8. Review how an athletic trainer makes an assessment on fitness to return to play after injuries to:

  9. Knee

  10. C-spine

  11. Ankle

  12. Head (concussion)

  13. Discuss the role of the A.T. to the team as well as how he/she can be a resource to the team physician.

Athletic Injury Management Objectives

Radiology

  1. State criteria for ordering an x-ray to diagnose a fracture or dislocation. Include literature consensus from the Ottowa ankle and knee rules.

  2. Correctly interpret common orthopedic x-rays and describe the findings in a conventional manner to other providers, verbally and in written form.

  3. Given negative findings on plain x-rays, list conditions where the following modalities could provide additional information for diagnosis:

  4. Bone scan following skeletal injuries

  5. CT or MRI following skeletal injuries

  6. CT or MRI following extremity or spine injuries.

Pediatric Conditions

  1. Describe the Salter-Harris classification system for growth plate injuries

  2. Identify common growth centers that could develop apophysitis

  3. Describe common presenting symptoms, physical exam findings, imaging results for the following conditions. Outline a management strategy and list indications for referral.

  4. Osgood-Schlatter disease

  5. Greenstick and torus fractures of the forearm

  6. Epiphysial fractures

  7. Pitcher’s elbow

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