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14 Articles in Volume 12, Issue #8
Board-certified Doctor Cleared of Criminal Charges for High-dose Opioid Prescribing
John F. Kennedy's Pain Story: From Autoimmune Disease To Centralized Pain
Key Clinical Pearls for Treating Headache Patients
Lest We Forget Pain Treatment Is a Stepladder Approach
Mathematical Model For Methadone Conversion Examined
Pain Management Coding Changes Can Sting, But Knowledge Can Help Ease the Pain
Pain Treatment—Then and Now
Platelet Rich Plasma Prolotherapy For Rotator Cuff Tears: Case Challenge
September 2012 Letters to the Editor
September 2012 Pain Research Updates
The Sports Injury-Pain Interface: Highlights from the American Orthopaedic Society for Sports Medicine Annual Meeting
Trigeminal Neuralgia: A Closer Look at This Enigmatic and Debilitating Disease
What Every Physician Should Know About Non-pharmaceutical Pediatric Pain Care
When Referring Patients, Not All Pain Specialists Are the Same

The Sports Injury-Pain Interface: Highlights from the American Orthopaedic Society for Sports Medicine Annual Meeting

September 2012 Dispatches from the Field

The Baltimore Convention Center in Maryland was the setting for the Annual Meeting of the American Orthopaedic Society for Sports Medicine (AOSSM), held July 12-15, 2012. The format of the meeting included workshops, scientific sessions, seminars, poster sessions as well as scientific platform sessions. Mark Young, MD, an Editorial Board member of Practical Pain Management, was in attendance and presents these highlights from the meeting.

Recognizing Pain and Disability in Athletes

Increasing recognition of the important consequence of pain and disability in the injured athlete has resulted in a proliferation of research into preventive measures as well as optimized therapeutic strategies. Sports-related injuries such as contusions, sprains, and strains can exert a negative effect on athlete performance and wellness. Pain that results from these conditions often leads to continuing disability.

Although a commonplace occurrence, sprains and strains are one of the most frequent causes of chronic pain in athletes. A sprain is a wrenching or twisting injury to a ligament. A sprain most commonly affects the ankle, wrist, or knee often leading to pain, swelling, stiffness, and reduced range of motion. A strain represents an injury to a muscle or tendon and can be induced by stretching, force, or overuse.

Specific painful conditions affecting tendons include:

  • Tennis elbow (lateral epicondylitis), which manifests itself with pain in the posterior portion of the elbow and in the forearm. The pain is exacerbated with resisted extension of the elbow
  • Golfer’s elbow or baseball elbow (medial epicondylitis) is characterized by pain extending from the elbow to the wrist on the palmer aspect of the forearm
  • Runner’s knee (patellofemoral stress syndrome) is caused by the patella (knee cap) rubbing against the femur. This condition can be provoked by structural defects, or poor walking or running technique
  • Jumper’s knee is frequently called patellar tendonitis and is caused by inflammation of the patella tendon.

Meeting Approach

In addressing the spectrum of painful conditions afflicting the population, presenters at this meeting offered conservative as well as surgical solutions. An instructional course on arthroscopy of the elbow reviewed the basic anatomy of the elbow as well as proper indications and complications of the procedure. An instructional course on treatment of patellofemoral pain offered a unique perspective into preventing and treating this condition. The course provided an overview of conservative management strategies and more invasive strategies, such as exercises, taping, mechanical measures, etc.

With respect to foot and ankle pain, a lively workshop titled, “The Land of Ligaments: Navigating Sprains, Strains, and Ruptures of the Foot and Ankle,” provided a deep dive into assessment and treatment of pain resulting from foot and ankle pathology. The anterior talofibular ligament is commonly the cause of much pain, discomfort, and structural compromise leading to biomechanical compromise in gait. The presenters talked about classical mechanisms of a sprained ankle.

Pain and Disability

Both the poster and platform research presentations at the AOSSM meeting focused on state-of-the-art developments in diagnosis, treatment, and management of sports conditions. Several honed in on pain and disability factors. A poster presentation on biomechanical analysis of massive rotator cuff tear repairs explored the important link between movement and rotator cuff pathology. The objectives of this study were to compare the biomechanical properties of single-row (SR), extended double-row (DR), and augmented, extended double-row (aDR) rotator cuff repairs in intact rotator cuff tendons.1 The researchers from Vail, Colorado, found that there was a significant difference in stiffness for SR (72.9 ± 4.64 N/mm) and aDR (72.6 ± 11.8 N/mm) repairs, compared to intact specimens (93.1 ± 14.8 N/mm). The intact specimens, DR, and aDR repairs endured significantly more cycles and had higher maximum load ranges at failure than SR repairs (P<0.05 for all groups). The authors concluded that all SR failed at the tendon-suture construct (6/6), and all aDR failed due to the sutures tearing through the tendons medially (6/6). The mechanism of failure for the DR repairs included lateral anchor pull out (2/6), sutures cutting through the tendon medially (2/6), and tendon failure at the musculotendinous junction (2/6). “Extended, linked DR constructs were significantly stronger than the SR repair in this model. Furthermore, augmentation with a collagen patch did not negatively influence the biomechanical repair qualities. However, there is still room for optimizing [massive rotator cuff tear] repairs,” they noted.

Return to Soccer After ACL Repair

Another presentation on gender-based differences in outcomes following anterior cruciate ligament (ACL) reconstruction in soccer athletes examined the musculoskeletal nuances of gender. The authors noted that “ACL injuries are common among soccer athletes, and occur at a higher rate in women compared to men.”

The study included a total of 94 soccer players (49 men, 45 women), and looked at whether there were gender differences in return to play and risk for future ACL injury in soccer athletes.2 Overall, 72% of athletes returned to soccer at an average of 12.5 months after surgery. “There was no significant difference between males and females in the rate of return (men 80% vs women 64%, P=0.1) or time to return to play (men 10.5 ± 7.5 months vs women 15.1 ± 20.7 months, P=0.3),” noted the researchers. Twelve athletes (13%) had undergone further ACL surgery, including 9 on the contralateral knee (10%) and 3 (3%) on the ipsilateral knee. Women were more likely to need additional ACL surgery (27%) than men (6%) (P=0.04). At an average follow up of 7 years, only 36% of soccer athletes who underwent ACL reconstruction were still playing the sport, a significant decrease compared to initial return to play (P<0.0001). There was no significant difference in the long-term return to play between men (41%) and women (31%) (P=0.3). However, men were more likely (59%) than women (29%) to attribute their ACL injury as the primary reason they were no longer playing soccer (P=0.02).

The authors concluded that soccer players have a good initial rate of return to play following ACL reconstruction, which declines over time. Men may be affected more directly than women by the injury itself as opposed to other factors or life events in terms of their potential return to play, they noted.

Postoperative Pain Management

Intra-articular injection of morphine was found to be as effective as bupivacaine for the management of pain following partial meniscectomy and abrasion chondroplasty of the knee, according to a result of a study led by Hussein Elkousy, MD, Fondren Orthopedic Group, Houston, Texas.3 The investigators wanted to compare the effectiveness of morphine because of recent reports that indicated that intra-articular administration of bupivacaine may harm hyaline cartilage.

The researchers prospectively studied 82 patients who were randomized to receive morphine 10 mg in a 10 mL volume of arthroscopy fluid (LR) or 10 mL of 0.5% bupivacaine administered immediately postoperatively. Pain scores based on the visual analog scale (VAS) and side effect profile were recorded in the post-anesthesia care unit (PACU), transitional care unit, and then every 4 hours postoperatively until 24 hours.

The authors found that the VAS scores in the PACU decreased from 3.4 on admission to 2.4 on discharge for the morphine group, and from 2.6 to 2.4 for the bupivacaine group with no statistical difference. VAS scores decreased from 3.0 to 1.5 between 4 and 24 hours postoperatively for the morphine group and from 2.8 to 1.8 for the bupivacaine group. The authors noted that “10 mg of intra-articular morphine is as effective as 10 mL of 0.5% bupivacaine for postoperative pain control. Morphine did not increase side effects and it circumvents the issue of chondral toxicity of bupivacaine.”

IV NSAID Use up Among Sports Medicine Physicians

Following the lead of their pro-team physicians, more sports medicine physicians are using intramuscular (IM) ketorolac (Toradol) injections for the management of pain on the playing field.4 “Pain control is a crucial factor in the sideline treatment of competitive athletes,” noted lead investigator Gregory Sawyer, MD. “We found that intramuscular ketorolac is being used by approximately 49% of sports medicine physicians in their care of athletes. These team physicians have noted a high rate of improved pain control and a low incidence of adverse reactions,” he stated.

Ketorolac is a non-steroidal anti-inflammatory medication that can be used in the treatment of acute pain. A survey of National Football League teams in 2000 revealed that 93% of teams administered ketorolac to players for pain control.5 However, there has been no research on its use in athletes at the high school, college, and professional levels. The most frequently cited reasons for not administering ketorolac include fear of renal failure and bleeding complications, although the incidence of these events is low.

To study how many physicians use ketorolac, the investigators sent a survey to approximately 4,750 orthopedic surgeons and 2,200 primary care sports medicine physicians. The total number of respondents was 1,100 (60% orthopedics, 40% primary care sports medicine physicians). The survey found that 94% of the respondents are involved in the direct care of athletes and 48.9% use IM ketorolac in their treatment. Of the primary care physicians who care for athletes, 57.3% use IM ketorolac compared with 38.1% of orthopedic surgeons. The most frequently recognized reasons causing respondents not to use IM ketorolac is fear of renal and bleeding complications. Post-injury pain (90.6%) is the most recognized indication for IM ketorolac use, and 95.8% feel that its administration decreases pain effectively in athletes. Few adverse reactions have been recognized with local skin reaction (5%), bleeding (2.9%), and kidney problems (1.9%) being the most frequent.


Last updated on: October 5, 2012
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