Workshop Name:
Practice-Based Learning in Sports Medicine: A Case-Based Approach in the Young Athlete
Date: Friday, November 14, 2014
Time: 2:30PM-4:00PM
Session Director: William Micheo, MD
Faculty: Gerardo E Miranda, MD and Rafael Acevedo, MD
Overview: Injuries to the young athlete poses special consideration in evaluation, diagnostic
approach, and treatment decisions. It is the responsibility of the physician to be familiar with
the guidelines specific to this population. This workshop focuses on the discussion of three
common injuries that raise questions on the most appropriate approach to reach clinical
decisions based on the scientific evidence.
Case #1: Medial elbow pain in a thrower
Controversial issues to discuss:
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Evaluation
o Overuse:1
 Age: developmental age
 Training load
 Sport-specialization
 Technique
 Medial elbow anatomy and biomechanical complexity
2-3
Diagnostic Studies
o Imaging studies
 MRI versus MSK US versus Plain X-rays versus CT scan
Differential diagnosis:4
o Ulnar collateral ligament injury
o Valgus extension overload
o Flexor-pronator injury/ Medial epicondylopathy
o Medial epicondyle apophysitis
o Ulnar nerve injury
o Osteochondral lesion
o Olecranon stress fracture
Treatment options
o Rehabilitation and/or non-surgical interventions: Regenerative medicine versus
surgical5-6
o Outcomes: Return to sport, recurrence7
Case #2: Chronic anterior knee pain in a basketball player
Controversial issues to discuss:
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Tendinopathy or tendinitis
Proximal versus distal pathology8
o Eccentric overload
Diagnostic Studies
o Ultrasound versus MRI9
Treatment:
o Medications
o Oral medications (NSAIDs)10 or Topical medication (Nitro-patch)11
o Injections
 PRP12-13 and/or Dry Needling or steroids
o Physical therapy14-17
 Eccentric strengthening protocol
o Surgery versus conservative treatment18
Case #3: Acute muscle injury in a young soccer player
Controversial issues to discuss:
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
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Mechanism of injury: eccentric versus concentric muscle contraction
Injury classification19
o Localization: Muscle fibers, muscle-tendon junction, tendon
o Proximal versus distal
Diagnostic Studies
o MRI and return to play correlation20-21
Treatment:
o Interventions
 PRP, autologous blood products, steroids22-23
o Eccentric exercise program24
Return to Play25
Suggested readings:
1. DiFiori JP, Benjamin HJ, Brenner JS, et al. Overuse injuries and burnout in youth sports: A
position statement from the american medical society for sports medicine. Br J Sports Med.
2014;48(4):287-288.
2. Timmerman LA, Schwartz ML, Andrews JR. Preoperative evaluation of the ulnar collateral
ligament by magnetic resonance imaging and computed tomography arthrography.
evaluation in 25 baseball players with surgical confirmation. Am J Sports Med.
1994;22(1):26-31; discussion 32.
3. Ciccotti MG, Atanda A,Jr, Nazarian LN, Dodson CC, Holmes L, Cohen SB. Stress sonography of
the ulnar collateral ligament of the elbow in professional baseball pitchers: A 10-year study.
Am J Sports Med. 2014;42(3):544-551.
4. Dugas J, Chronister J, Cain EL,Jr, Andrews JR. Ulnar collateral ligament in the overhead
athlete: A current review. Sports Med Arthrosc. 2014;22(3):169-182.
5. Ben Kibler W, Sciascia A. Kinetic chain contributions to elbow function and dysfunction in
sports. Clin Sports Med. 2004;23(4):545-52, viii.
6. Podesta L, Crow SA, Volkmer D, Bert T, Yocum LA. Treatment of partial ulnar collateral
ligament tears in the elbow with platelet-rich plasma. Am J Sports Med. 2013;41(7):16891694.
7. Osbahr DC, Cain EL,Jr, Raines BT, Fortenbaugh D, Dugas JR, Andrews JR. Long-term outcomes
after ulnar collateral ligament reconstruction in competitive baseball players: Minimum 10year follow-up. Am J Sports Med. 2014;42(6):1333-1342.
8. Pearson SJ, Hussain SR. Region-specific tendon properties and patellar tendinopathy: A
wider understanding. Sports Med. 2014;44(8):1101-1112.
9. Warden SJ, Kiss ZS, Malara FA, Ooi AB, Cook JL, Crossley KM. Comparative accuracy of
magnetic resonance imaging and ultrasonography in confirming clinically diagnosed patellar
tendinopathy. Am J Sports Med. 2007;35(3):427-436. 1.
10. Paoloni JA, Milne C, Orchard J, Hamilton B. Non-steroidal anti-inflammatory drugs in sports
medicine: Guidelines for practical but sensible use. Br J Sports Med. 2009;43(11):863-865.
11. Steunebrink M, Zwerver J, Brandsema R, Groenenboom P, van den Akker-Scheek I, Weir A.
Topical glyceryl trinitrate treatment of chronic patellar tendinopathy: A randomised,
double-blind, placebo-controlled clinical trial. Br J Sports Med. 2013;47(1):34-39.
12. Dragoo JL, Wasterlain AS, Braun HJ, Nead KT. Platelet-rich plasma as a treatment for patellar
tendinopathy: A double-blind, randomized controlled trial. Am J Sports Med.
2014;42(3):610-618.
13. Charousset C, Zaoui A, Bellaiche L, Bouyer B. Are multiple platelet-rich plasma injections
useful for treatment of chronic patellar tendinopathy in athletes? a prospective study. Am J
Sports Med. 2014;42(4):906-911.
14. van Ark M, van den Akker-Scheek I, Meijer LT, Zwerver J. An exercise-based physical therapy
program for patients with patellar tendinopathy after platelet-rich plasma injection. Phys
Ther Sport. 2013;14(2):124-130.
15. Frohm A, Halvorsen K, Thorstensson A. Patellar tendon load in different types of eccentric
squats. Clin Biomech (Bristol, Avon). 2007;22(6):704-711.
16. Frohm A, Saartok T, Halvorsen K, Renstrom P. Eccentric treatment for patellar tendinopathy:
A prospective randomised short-term pilot study of two rehabilitation protocols. Br J Sports
Med. 2007;41(7):e7.
17. Visnes H, Bahr R. The evolution of eccentric training as treatment for patellar tendinopathy
(jumper's knee): A critical review of exercise programmes. Br J Sports Med. 2007;41(4):217223. 12.
18. Bahr R, Fossan B, Loken S, Engebretsen L. Surgical treatment compared with eccentric
training for patellar tendinopathy (jumper's knee). A randomized, controlled trial. J Bone
Joint Surg Am. 2006;88(8):1689-1698.
19. Mueller-Wohlfahrt HW, Haensel L, Mithoefer K, et al. Terminology and classification of
muscle injuries in sport: The munich consensus statement. Br J Sports Med. 2013;47(6):342350.
20. Reurink G, Brilman EG, de Vos RJ, et al. Magnetic resonance imaging in acute hamstring
injury: Can we provide a return to play prognosis? Sports Med. 2014.
21. Ekstrand J, Healy JC, Walden M, Lee JC, English B, Hagglund M. Hamstring muscle injuries in
professional football: The correlation of MRI findings with return to play. Br J Sports Med.
2012;46(2):112-117.
22. Hamid MS, Mohamed Ali MR, Yusof A, George J, Lee LP. Platelet-rich plasma injections for
the treatment of hamstring injuries: A randomized controlled trial. Am J Sports Med.
2014;42(10):2410-2418.
23. Reurink G, Goudswaard GJ, Moen MH, et al. Platelet-rich plasma injections in acute muscle
injury. N Engl J Med. 2014;370(26):2546-2547.
24. Mason DL, Dickens VA, Vail A. Rehabilitation for hamstring injuries. Cochrane Database Syst
Rev. 2012;12:CD004575.
25. Delvaux F, Rochcongar P, Bruyere O, et al. Return-to-play criteria after hamstring injury:
Actual medicine practice in professional soccer teams. J Sports Sci Med. 2014;13(3):721-723.