Delaware Sports MedicinePearls from a 30-Year Experience

Michael J. Axe, M.D.Partner, First State OrthopaedicsProfessor, University of Delaware

Chair, SMAC of DIAA

Pearls(aka Axe-isms)

• Necessities

– Critical to patient outcome

• Niceties

– May improve performance or healing time

AXE-ISMS

1) Be a Splitter

2) Educate your colleagues

3) Educate and respect your patients

4) Document your findings

5) Happiness is founded on Good Rehabilitation

6) Univ. of Delaware PT department is a great resource

7) Research is hard work

8) Safe return to play needs guidelines

9) Be active in your “communities”

10) Recycle Durable Medical Goods

Axisms

Be a splitter” You’d expect this from an Axe! “

Accurate Diagnosis Specific Grade

Grade

- Treatment

- Prognosis

- Communication

Effusion Grades: modified sweep test• Trace: small fluid wave with superior

pouch compression

• +1: larger fluid wave with superior pouch compression

• +2: fluid wave spontaneously returns

• +3: too much to milk into pouch

In rehab +1 or less – OK to progressSturgill et al. JOSPT 2011

AXE-ISM: Educate your colleagues

Wrong views = repeat X-ray/annoyed patient

Hurts so Good, Hurts so Bad

NSAIDS – Dose to Size

Injections are worth it (good care and good $)

AXE-ISM “Wrong views = repeat

X-ray/annoyed patient”

• Shoulder series

• Wrong views

– A/P IR

– A/P ER

• Best views

– A/P

– Axillary lateral

– Outlet

AXE-ISM “Wrong views = repeat X-ray/annoyed patient”

• Knee series

• Wrong views– A/P non-weight

bearing

– A/P weight bearing straight knee

• Best views– P/A weight bearing

bent knee (20 degrees)

– Sunrise (patella)

– Lateral bent knee (30 degrees)

MRI/CTScan

• Need contrast

• r/o

– Loose body

– SLAP

– Redo rotator cuff

– Redo ligament repair

AXE-ISM“Hurts so Good, Hurts so Bad”

Good

Post Exercise

Gradual Onset

Dull

Generalized

Kink

Works out with motion

Tired arm NOT Dead arm

Sx’s with Rest & warm up

Bad

During exercise

Sudden Onset

Stabbing Knife-Like Pain

Exercise Shut Down

Altered Mechanics

Loss of Breath

Pool, AI, Rest = NO HELP

Night pain

Dose of NSAIDS• 2 weeks @ max dose• Continue for one week more than you’re sore• Many different families

• Dose dependent on size of patient– Less than 150 lbs– Less than 200 lbs– Less than 250 lbs

• Acute vs Chronic

Additional Anti-inflammatory Steroid Dose Pack

• Prednisone

– 60 mg daily x 5 days

– take with largest meal

• Indications

– Bee sting reaction

– asthma

– acute inflammation

Vitamin E 1600 units

Spraying is fundamentalKnees are easySubacromial injections are not hardTennis elbow hurtsAnkles are the futureSmall joints have small spaces Wet joints/Dry joints

Aspirations

big needle big syringe

AXE-ISM “Injections are worth it”

Injections• Repeat injections (2-4)

• Pseudo-septic reactions

– Treatment algorithm“Shot Clinic”

Spraying is fundamental

Make your mark

Knee injections are easy

Aspirations are not so easy! Ultrasound?

Dr. Scott Dye

Subacromial injections are not hard

• Provocative reduction

Wet joints/Dry joints

Lubricants for ‘Dry Joints’

• Tin Man Therapy– 3 in one for the dry joint

• Wet joints – get dry 1st if possible

Knee Aspiration

• Uncontrolled Pressure Pain

• < 90 degrees flexion

• > 5 degrees lack of full extension

• Unable to initiate SLR

18 gauge Needle; 50 cc syringe

AXE-ISM: Educate your patients

• The wall does it all…electronically!

Number One: When can I ...Drive?

• What do the data say?

• Gotlin and colleagues (Arch Phys Med Rehabil 2000, Arthroscopy 2000)– Brake reaction time normal 4-6

weeks after right ACL

• Nguyen and colleagues (Knee Surg Sports Traumatol Arthrosc 2000)– Reaction time normal 6 weeks after

right ACL

– Sit-to-stand 6 in 10 sec

– Step test 15 in 10 sec - useful

Goals: BE FUNCTIONAL!

A. Control Pain and Swelling

B. Restore ROM

C. Restore Strength

AXE-ISM: Happiness is founded on

Good Rehabilitation

“Your PT colleague is your best friend”

Good Rehabilitation“The patient is not always right”

0

200

400

600

800

1000

1200

1400

1600

0 500 1000 1500 2000 2500

Time (ms)

Forc

e (N

)

Necessity - Nicety• NMES can be used at any time

during the rehabilitation phase after knee surgery

• NMES is superior to voluntary exercise in increasing isometric strength of knee extensors after ACL reconstruction*

• Need a STRONG stimulator

*Snyder-Mackler et al J Bone Joint Surg 1995

Fitzgerald et al JOSPT 2005

Good Rehabilitation

NecessitiesA. Understanding of soft tissue healing & fixation techniques

B. Diagnosis Driven Programs

C. Objective Criteria for Progression

D. Significant “Hands On Time” per visit

E. Office call for variance

F. Appropriate Home Exercise Program (HEP)

G. Discharge criteria with outcomes

Good Rehabilitation

PT understands soft tissue healing & fixation techniques

Rehab Modified Surgery Surgery Modified Rehab

Surgeon attempts Rigid Fixation Tissue issue

Screws Stitches

Fixation: Race between healing vs. fixation failure

Good RehabilitationDiagnosis Driven Programs

– Protocols: A Good Start

– Programs

• Functional – Simulates the activity

• Practical - < 60 minutes

• Progressive

Functional Progression

Start

Finish

Lateral ankle sprain

Good RehabilitationObjective Criteria for Progression

• Don’t forget Healing Principles

• Soreness Rules

• Effusion testing

Objective Criteria for Progression

Criterion

1. Soreness during warm-up that continues

2. Soreness during warm-up that goes away

Action

2 days off, drop down 1 step

Stay at step that led to soreness

SORENESS RULES (1-5)

3. Soreness during warm-up that goes away but redevelops during session

4. Soreness the day after lifting (Not muscle soreness)

5. No Soreness

2 days off, drop down 1 step

1 day off, do not advance program to the next step

Advance one step per week or as instructed by healthcare professional

Objective Criteria for Progression

SORENESS RULES

Good Rehabilitation

Significant “Hands On Time”

• Use the Gym if that’s all they needVisits/wk Reason

4-5 Swelling &/or pain control

Joint Mobilization

3 ROM, Pain control, Strengthening/early phase

2 Strengthening / late phase Functional advancement

Good Rehabilitation

Office call for Variance

#1 Temp increase with an angry wound

• Failure to Progress – “The 3 S’s”

– Re-evaluation (See)

– Subspecialty consultation (Send)

– Injections (Shoot)

Good Rehabilitation

Office call for Variance

• Injection shoulder

– morbidity 50%

• Provocative Reduction

– Hurt

– Help

Good Rehabilitation

Home Exercise Program requires 3 visits

• Patient Understanding1 – 60%

2 – 80%

3 – 90%

• Patient Compliance– Feels Better - compliance

Discharge Criteria & OutcomesGuidelines - Dx / # of visits

Community

Tennis elbow 8*-16 10-12

Rot. Cuff Tendinitis (no tear) 8*-15 10-12

Patellofemoral (no strength deficits) 8 8-12

Quadriceps Tendinitis 10 10-12

Patellar Tendinitis 14 10-12

Hamstring Strain (no rent) 8 6-12 (sport dependent)

Postop Meniscectomy 8 6-8

Postop ACL (isolated) 20 16 ± 5

Achilles Tendinitis 8 10-12

Grade II lateral ankle sprain 12 6-8 visits

Plantar Fasciitis 10*-20 10-12 (could be a lot)* - injection

Ask the N.I.H.

• Over $ 20 million to investigate rehab after…

AXE-ISM“UDPT is a Great resource”

Achilles & Patellar tendinopathy

1. Patients with tendinopathy

ACL

• Acute ACL injured

• ACLR who want to return to sports

Total Knee & Hip

1) Healthy people with isolated knee OA

2) Preoperative and postop unilateral TKA and THA

3) Ages 50-85 y/o

4) No diabetes“We’re #2!”

AXE-ISM: Document your findings

• Clinical

• Operative

• Make it prospective!

“Retrospective research is the worst!”

“It takes time”

AXE-ISM“Research is Hard Work

Especially in Private Practice”

Sustained commitment –for more than 30 years

How to get your research projects started (Even if you’re in Private

Practice)

Michael J. Axe, MD

Lynn Snyder-Mackler, PT, ScD, FAPTA

AOSSM Research Symposium Quebec City 2004 and Keystone 2005

Reasons to do research

• Acceptance to Fellowship/Residency/Med School

• Tenure and Promotion

• Notoriety- practice builder

• BURNING QUESTIONS

Absolutes for success

I. Question must be answerableBest: yes or no

II. Team – Necessary Skills

III. Funding

IV. Adequate research subjects

V. Team time availability

VI. Site with all the necessary equipment

The Question

Hypothesis Driven

Team –Necessary Members for Success

• Dreamer

• Logistics/Design

• Conscience

• Analyst

• Worker Bees

• Manager/ Captain

Team - Dreamer

• Feels the fire

• The energy

• Usually their question

Team- Logistics/Designer

• Materials and Methods

Team – Conscience

• Stay on mission

• Keep the project important

• And (clinically) relevant

Resist the urge!

Team Analyst

• Data Interpretation

• Results

Team – Worker Bees

• Grad Students• Undergraduates• Post-docs• Technicians• Volunteers• Residents and fellows

– Not typically– Need dedicated time

• Protected• Consistent

Team- Manager/ Captain

• Question understanding/Interest

• Pub Med published

– In area of question (gold star)

• Regularly available to the team

• Private Practice Orthopedic Surgeon

– Rarely qualified

Funding

• “From seed money grants grow”

Funding • Self

• University (Internal)

• Small foundations– FPT/NATA/FISSM

• Larger foundations– OREF/ Aircast/Arthritis Foundation

• NIH

Adequate Research Subjects

• Provider of Patients (PoP) - take this role seriously!– Track record

• Dissertation committee

– Not just lip service

– Understand patient base and mix

• For duration of study– Month/years vs years/decades

• Human subjects committee approval– Necessary to publish

Team Availability

• Coordinated data retrieval

Site / Equipment

1st project – Burning question

• Since the supraspinatus is the most frequently injured tendon in baseball, can it be protected by functional off season overload with a weighted glove in a “gym sized” space

Answer “Yes”

But…no one knows

Few presentations and…

NO PUBLICATIONS

Burning question #2

Can a data based distance or speed based throwing program be

developed for youth baseball?

Project 2 - AssessmentSuccess! – AJSM vol 24, no 5, 1996

Are you special/talent protection cards

Background• 1996 Speed/Distance Validated*

– 853 USA youth baseball players• 8-14 years old

– Validated in new sample of 114 players

• Tool for player classification in USA

• No radar gun required• Data card created

The World of Youth Baseball

Data CardsDISTANCE SPEED

Yellow = 26/10,000 Orange= 1/100,000 Red= 1/1,000,000

? Are these data applicable internationally?

Venezuela Dominican Republic

Puerto Rico Japan

Cuba?

Achievement of Distinction and Outstanding Original Research Manuscript

of 2014 from the Sports Physical Therapy Section of the APTA

AXE-ISM: Safe RTP needs guidelines• Mantra of research - Directional and clinically

relevant– RTP is the theme of all my work

• My motivation came early– Dick Ray’s mother had a hip fracture

– Axe to Fiesta bowl alone (between Fralic and Maas)

– Few rules - to beg borrow or steal

– Sideline decision making: a player’s experience

– RTP – little science• Functional progression (What’s that??)

– Soreness rules

» Had to write them

30 years later: Sport Specific ProgramsUpper Extremity(www.udel.edu/PT)

• Weight lifting

• Interval Throwing Programs

– Baseball and softball (all ages, all levels, all positions), tennis, volleyball

Do’s

&

Dont’s

Weight training modifications to decrease injuries and protect surgery

3% Rule

Development of a Distance Based Interval Throwing Program for Little League Age

Athletes

Interval Throwing Programs for Infielders and Outfielders

Adolescent Throwing Programs

A Committed Faculty Member: Teaching * Research * Service

More than 300 invited and scientific presentations

70+ hours/year of teaching Orthopaedics course to MPT/DPT students for 25 years

HSAEC (University Pre-med Advisory

and Evaluation Committee) 15 years

Medical Director of the UD Sports PT

Residency

Member of >10 PhD dissertation committees

Investigator on 15 NIH Grants More than 75 articles in peer-

reviewed journals

UD Biomedical Engineering External Advisory Committee

AXE-ISM: Be active in your “communities”

• Chairman, Sports Medicine Committee, Delaware Interscholastic Athletic Association• Team Physician/Orthopaedist - Wilmington University• Team Physician/Orthopaedist - Goldey Beacom College• AOSSM STOP Sports Injuries Steering Committee• Youth In Sports, Channel 28, Co-host/WDEL 1150 Color Analyst• Boys and Girls Clubs of Delaware Corporate Board/Medical Consultant• Beast of the East Medical Director

• Delaware Wrestling Alliance, Board Member and Medical Consultant• Delegate to the American Orthopaedic Society for Sports Medicine• Catholic Youth Ministries of Delaware, Medical Director • Governor’s Council on Lifestyle and Fitness Member• Delaware Lacrosse Foundation, Board Member and Medical Consultant

AXE-ISM“Recycle Durable Medical Goods”

Collection Sites!!!

First State Orthopaedics – Axe offices

U of D Physical Therapy – STAR

ATI Physical Therapy

Crutches, knee immobilizers, air casts, wrist splints, slings

Benefited more than 1000s of teams and organizations

Thank you