Risk of Septic Arthritis Higher in Pro Athletes – https://ryortho.com/

Diagnosing young patients presenting with swollen knees can get dicey. Does the child have infectious arthritis of the knee or Lyme disease? A new study in the May 4 issue of The Journal of Bone and Joint Surgery identifies four symptoms that are predictive of septic arthritis in children.

According to the May 11, 2016 news release, “Septic arthritis is considered a medical emergency requiring surgical irrigation (flushing) and drainage to prevent rapid and irreversible destruction of the cartilage surrounding the knee. Lyme disease, an infection common in the northwest and northeast parts of the U.S. and caused by bacteria normally found in deer and transmitted to humans through ticks, is treated with antibiotics. In addition to knee swelling and pain, both conditions may cause a fever, swelling of other joints, irritability and an inability to bear weight on the affected extremity. Common laboratory tests to measure inflammation, as well as white blood cell counts, also may be elevated.”

“In the new study, researchers reviewed the records of 189 patients under age 18 who presented to Children’s Hospital of Philadelphia (CHOP) with excess fluid in the knee between 2005 and 2013. Of these patients, 23 had culture-positive septic arthritis; 26, culture-negative septic arthritis; and 140, Lyme disease.”

“The study authors found four characteristics that are predictive factors for septic arthritis: Knee pain with a short range of motion; A C-reactive protein (CRP test; used to measure inflammation) of >4.0 mg/L; Fever; Age younger than 2.”

“The probability of septic arthritis with any one factor present was 18% compared to 100% will all four factors present, ” said study author Wudbhav N. Sankar, M.D., an orthopedic surgeon at CHOP. “Our study offers a useful prediction algorithm to help distinguish septic arthritis from a knee effusion caused by Lyme disease in children.”

Dr. Sankar told OTW, “In this era of precise and detailed laboratory testing, we were surprised at how important the physical exam component (i.e., pain with short motion) was in distinguishing Lyme disease from septic arthritis.”

“Our predictive model demonstrates clear direction for patients on either end of the model: Those with all four risk factors (pain with short arc knee motion, CRP >4, history of fever, and age <2) should clearly be treated as septic arthritis with urgent surgery while those with zero risk factors can be safely observed.

Two research teams at the Hospital for Special Surgery (HSS) have recently been awarded grants by the NBA and GE Healthcare Orthopedics and Sports Medicine Collaboration to study bone stress injuries affecting NBA players and other athletes.

A research team led by Brett Toresdahl, M.D., a Hospital for Special Surgery primary care sports medicine physician, received an almost $300,000 grant to evaluate the use of ultrasound imaging to monitor healing and guide proper return to play in athletes with bone stress injuries.

Because signs of healing are difficult to see on standard imaging like MRI and X-ray, it is difficult to determine when an athlete is ready to return to the game.

“There is little known about the connection between ultrasound findings, symptoms, and readiness for return to sport for athletes with bone stress injuries,” said Dr. Toresdahl, principle investigator of the study in a press release.

“Our goal is to evaluate the use of serial ultrasound to assess bony healing to optimize treatment and more accurately predict readiness for return-to-play.”

During the study, adults between 18 and 50 years of age who have had a bone stress injury in the lower leg or foot during sport or exercise will undergo traditional treatment, but in addition an ultrasound will be performed every 2 weeks for 12 weeks. The patients will also be asked to keep track of their pain and return to activity. A MRI will also be performed at 12 weeks.

“Our findings could provide doctors with a new way to guide athletes to safely return to play after a bone stress injury with a minimal risk of re-injury,” Toresdahl said.

HSS foot and ankle surgeon, Martin O’Malley, M.D., and his team also received a grant. They were awarded $100,000 to assess risk factors and intervention strategies for fifth metatarsal stress fractures, which is a common type of stress fractures for basketball players that can be difficult to treat.

“Currently, there is limited knowledge on how to identify athletes who are at a high risk for a fifth metatarsal stress fracture,” said O’Malley, said in the release.

“Additionally, we don’t have a clinical understanding on how to intervene before such injury occurs.”

Doctors are divided on the benefits of platelet-rich plasma injections to treat hamstring muscle injuries. Hamstrings are the muscles located at the back of the thigh that are essential for flexing the hip and knee.

Gustaaf Reurink, a sports medicine specialist with Erasmus Medical Center in Rotterdam, the Netherlands, conducted a study in which researchers gave either two injections of platelet-rich plasma or saline to 80 athletes with hamstring injuries. They tracked both groups of athletes for six months and found that the treatment appeared to have no effect on the time required for them to return to sports or be reinjured.

For both groups the median time in which they could start playing sports again was 42 days. About 15% of both groups reinjured themselves. Reurink and his group published their findings in the June issue of the New England Journal of Medicine.

Randy Dotinga, a HealthDay writer, reported that Lewis Maharam, M.D., a sports medicine specialist in New York City, disagrees, saying that platelet-rich plasma injections have made a big difference. Dotinga quotes Maharam as saying, “When it’s done correctly, patients heal in 2 or 3 weeks maximum and they’re back running.” In the past, he said, pro-football players with torn hamstrings were kept off the field for 8 to 12 weeks to recover using a program of rest and physical therapy.

Dotinga quotes Maharam as suggesting that the researchers did not flood the injured hamstrings via the injections or adjust the amount of plasma based on the size of the injury. Reurink responded that the researchers used the treatment amount recommended by the manufacturer of the plasma materials.

Dotinga notes that there is no research showing that the treatment works on hamstring injuries and, because it is experimental, insurance companies will not cover the cost of the treatment. Single injections, according to Reurink, cost from $500 to $1, 000.

The ideal number of injections for a ham string injury has not been determined. According to the American Academy of Orthopaedic Surgeons, the treatment is being used for other tendon injuries such as tennis elbow, ligament and muscle injuries and knee arthritis.

The American Academy of Family Physicians (AAFP), the American College of Sports Medicine (ACSM) and four other medical organizations released a team physician consensus statement that outlines best practices for injury and illness prevention for athletes at all levels of expertise.

The statement, published in Medicine & Science in Sports & Exercise and Current Sports Medicine Reports, provides recommendations on musculoskeletal injuries, head and neck injuries, heat illness, cardiovascular issues, equipment and injury reduction/modification, and skin infections. The statement updates one issued in 2007. Other groups involved in developing the statement were the American Academy of Orthopaedic Surgeons (AAOS), the American Medical Society for Sports Medicine (AMSSM), the American Orthopaedic Society for Sports Medicine (AOSSM) and the American Osteopathic Academy of Sports Medicine (AOASM).

Key recommendations in the document include the importance of up-to-date treatment information for athletes, the role of sport-specific prevention programs and cautions regarding equipment safety. The statement addresses topics such as return-to-play decisions, concussion treatment, sideline preparedness and psychological issues.

“This paper offers guidelines for practice in the areas of injury and illness most commonly seen by team physicians, ” said Stanley Herring, M.D., clinical professor in the departments of Rehabilitation Medicine, Orthopaedics and Sports Medicine, and Neurological Surgery at the University of Washington School of Medicine in Seattle. “It provides a roadmap of common issues facing medical professionals on the sidelines and in their offices.”

Jason Matuszak, M.D., of Buffalo, New York, is a sports medicine specialist who participated in the expert panel that developed the consensus statement. He said that the statements “serve as a guide for physicians who provide sports medicine services in their community but may not have formal training in sports medicine. Commonly injured joints include the shoulder, knee and ankle, and common medical problems include heat illness, skin infection and concussion. Ideally, we are working toward injury prevention, or at least mitigation, ” he said.

Matuszak warned that some equipment is being marketed with untrue claims that it will prevent injury. He said, “Given the growing concern and attention to youth sport safety and the potential for vendors to market to that concern, it is important for physicians dealing with athletes to be able to counsel patients and their parents about what equipment may or may not improve safety, or at least refer them to appropriate resources”

The statement is available here.

Not aggressively treating the Female Athlete Triad could lead to potentially season-ending bone stress injury, according to new research published in the December issue of The American Journal of Sports Medicine.

The Female Athlete Triad is a syndrome in which eating disorders (or low energy availability), amenorrhoea/oligomenorrhoea, and decreased bone mineral density (osteoporosis and osteopenia) are present.

Researchers from Stanford University and Harvard Medical School categorized college athletes involved in 16 sports by risk level for bone stress injury—low, moderate, high—based on their Female Athlete Triad Cumulative Risk Assessment Score. Of the 239 athletes assigned a risk category, 61 (25.5%) were considered of moderate or high risk. The most common sports that these athletes were involved in were gymnastics, lacrosse, cross-country, swimming/diving, sailing and volleyball.

The next step was to review subsequent bone stress injuries. The researchers discovered that 25 athletes (10.5%) had experienced one or more. According to the data, those athletes in the moderate-risk group had double the risk of those in the low-risk group, and that risk almost quadrupled for those in the high risk category.

Another interesting finding was that cross-country runners accounted for most of the bone stress injuries (16; 64%).

One of the lead researchers, Adam S. Tenforde, M.D. of the Spaulding Rehabilitation Hospital, Spaulding National Running Center and of the department of physical medicine and rehabilitation at Harvard Medical School in Cambridge, Massachusetts, explained to OTW that long-distance running causes “cumulative repetitive load on the skeleton.”

“We suspect both behaviors of cross-country athletes and demands of the sport places these athletes at high risk for injury.”

Tenforde added that “part of what has made the Triad challenging to manage is coming up with criteria to understand how to gauge risk for the athlete. This is one reason I think this article is important: It identifies that a significant number of elite female athletes are at moderate or high risk for the Triad.”

“The high likelihood for sustaining a bone stress injury (on average within one year of their score being determined) highlights this is not just a theoretical risk.