Not all sports injuries need specialist care
From the July-August ACP Observer, copyright © 2005 by the American College of Physicians.
By Deborah Gesensway
The patient limps into your office complaining of knee, ankle, elbow, shoulder or other limb pain. Like most internists, you probably take one of two approaches: You refer the patient to an orthopedic surgeon, rheumatologist or sports medicine specialist. Or you prescribe an anti-inflammatory, plenty of rest and a return visit in a few weeks if the problem persists.
While those care options may be common, neither of them may help your patient—or your practice. Refer to a specialist, and you've likely delayed treatment and pain relief for a week or two. And while rest and anti-inflammatory drugs are often accepted as internal medicine's cure for musculoskeletal problems, they could actually prolong the problem.
Because musculoskeletal complaints account for one-fifth to one-third of all problems primary care physicians handle, they represent a potentially significant chunk of business for many internists, particularly in areas where orthopedic specialists are always booked up.
As a result, more internists are learning how to handle musculoskeletal issues and getting involved in sports medicine. While some call themselves sports medicine specialists, others see themselves as general internists who treat musculoskeletal problems.
What they have in common is a willingness to tackle issues that have long vexed internists, and a desire to convince colleagues to improve their training in musculoskeletal medicine.
The demographic case
Primary care sports medicine has traditionally been the province of family physicians, attracting many fewer pediatricians, internists, and emergency and rehabilitation physicians. Since the advent of formal sports medicine fellowships in the 1980s, however, and the establishment of a certificate of added qualifications by the American Board of Internal Medicine (ABIM) in 1993, primary care sports medicine has been slowly adding more internists to its ranks. (According to the ABIM's Web site, 130 sports medicine certificates had been issued as of 2003.)
Internists who practice primary care sports medicine point out that as many as 90% of all sports injuries do not require surgery—and that many more patients are getting and staying active into their senior years.
"The majority of my practice are people with full-time jobs who also want to participate in sports and be active," said Balu Natarajan, ACP Member, a sports medicine general internist in Chicago, who lists a 72-year-old attorney training to compete in a triathlon among his patients.
The demographics can be persuasive. John J. Leddy, MD, associate professor of clinical orthopedics and program director for the primary care sports medicine fellowship at the State University of New York at Buffalo in Buffalo, N.Y., said he entered the field because he was overwhelmed by patients with musculoskeletal problems during his first year as a general internist in western New York state.
"One of my offices was in the country," he said, "and there were lots of people coming in with twisted knees and ankles and hip pain from working on the farm or playing high school sports." When he found himself referring those patients, "I was thinking, 'Why should I have to refer this out? This isn't hard.' "
Part of the reason why internists are quick to refer is they receive little or no training in treating such complaints. Dr. Leddy, for instance, said he received little training in orthopedic medicine during his residency. He eventually took a one-year fellowship in sports medicine at the University of Buffalo and has been practicing sports medicine for the past 12 years.
The irony is that, while musculoskeletal complaints aren't really addressed in training programs, they make up a big part of internal medicine practice. "What happens is that we didn't have the training in residency, but when we get out into practice we see lots of patients who have musculoskeletal concerns," explained internist Philip H. Cohen, MD, assistant team physician for Rutgers University Sports Medicine in Piscataway, N.J.
That lack of training affects how internists care for musculoskeletal problems. While physicians may rely on rest and other conservative management strategies, primary care sports medicine specialists say that's not necessarily the best way to go.
"With shoulders and elbows especially, if you rest them, they get stiff," said Amy Powell, ACP Member, a Salt Lake City internist who specializes in primary care sports medicine. "If somebody has to wait two or three weeks for an orthopedic consultant and is getting stiff for those two or three weeks, that can actually create more problems than the patient's initial complaint."
Lack of sports medicine experience is another problem. Some sports medicine practitioners say some colleagues treat orthopedic injuries less seriously than other medical problems.
"You're not always dealing with the same sort of life-or-death situation that you are when a person comes into the ER with crushing substernal chest pain," said Dr. Cohen, who lectured on sports medicine at this year's Annual Session. "But what if a patient's shoulder injury prevents them from being able to work or care for their children? Or what if what appears to be a musculoskeletal injury is actually referred pain from something very serious?"
And a conservative approach doesn't reflect the evidence about best practices. While many physicians feel it's better to err on the side of playing it safe, "a lot of time they really should be doing something a lot sooner," said David S. Ross, ACP Member, director of the Methodist Health System primary care sports medicine fellowship in Dallas and associate professor at Dallas' University of Texas Southwestern Medical Center. Dr. Ross is also a co-editor of the College's "Expert Guide to Sports Medicine." (See "ACP debuts new sports medicine book." For online help, see "Sports medicine resources.")
Take ankle sprains. Patients are frequently told to ice the ankle, take an anti-inflammatory, use crutches for 10 days and then come back for another visit. Instead, "we want to see range-of-motion and weight-bearing activities start as soon as possible," Dr. Ross said. Otherwise, an ankle sprain that should be resolved in two weeks or less may not get better for three or four weeks.
The same holds true, he added, with a knee injury. "If you tell the patient, 'Put it in an immobilizer and see me in two weeks,' they won't be able to bend or flex their knee." (He was quick to point out, however, that physicians can also move patients to range-of-motion and weight-bearing activities too soon, which also causes problems.)
Another treatment approach that's changing is the long-term use of anti-inflammatory drugs, said Salt Lake City's Dr. Powell. This winter, the FDA convened an advisory panel to debate the future of the COX-2-type anti-inflammatory drugs and their predecessors, the COX-1s, which include the popular over-the-counter drug, naproxen.
"We have to come up with other options that can treat patients' pain and get them back to better function without depending on anti-inflammatories as a crutch," Dr. Powell said. She uses short-term NSAIDS in combination with appropriate doses of acetaminophen for pain relief—and gets patients early into physical therapy.
Besides, Dr. Cohen pointed out, anti-inflammatories probably won't cure musculoskeletal injuries.
"Chances are there is an underlying process that has caused this problem, and if you just throw some medicine at it, you haven't altered the pathological factors," he said. "Even if they do get better temporarily, what are the chances they are going to come back? And what if the condition is such that in the interim it gets worse because you didn't act appropriately?"
Recognizing basic injuries
The good news, physicians say, is that learning to treat many straightforward musculoskeletal problems isn't that hard. (Also see "Common sports medicine issues.")
According to Dr. Cohen, internists already have the most important skill they need: how to listen to a patient and take a good history. To apply that skill to musculoskeletal problems, internists need to learn the most common injuries that occur in each body area, and how they present.
After listening to the patient's concerns, ask specific questions to narrow down the differential, then use a focused physical exam to confirm or refute the diagnosis. According to Dr. Cohen, "90% of the diagnosis will come from a good history."
For example, "for skinny, 17-year-old cross-country runners who have kneecap pain in both knees, that diagnosis is 95% of the time going to be patellofemoral pain syndrome," said Dr. Natarajan, who also lectured on sports medicine at this year's Annual Session.
What about 50-year-old patients who present with shoulder pain but can't remember any specific injury? If they feel pain when they reach to get something out of a cabinet or the shoulder hurts like a toothache when they roll over on it at night, Dr. Natarajan said, that is a bruised or partially torn rotator cuff.
"If you become proficient at these common knee and shoulder injuries," he added, "you will probably cut down by two-thirds the need to call a sports medicine specialist."
Finally, another big reason for general internists to improve their sports medicine skills is to make a strong push for disease prevention. (See also "Preparticipation screening exam: a golden opportunity for prevention.")
When Dr. Powell sees a 55-year-old patient with diabetes, hypertension or heart disease, for instance, she routinely talks about exercise as medicine.
"I tell them, 'If you were to start exercising, you would be more physically fit, you would have better glucose control and may be able to reduce your medications,' " she said. "I think of it as a medicine: Take it every day, do it every day, but let's start slowly."
Dr. Cohen agreed that preventive medicine is a huge part of what he does. "When evaluating someone who wants to start exercising, it's a great time to say, 'Let's take a look at your biomechanics. Let's look at your gait. Let's talk about what footwear you are going to need, and let's talk about stretching,' " he said. That's also the time, he added, to review the appropriate type and intensity of exercise for individual patients, as well as counsel them on proper nutrition and rest.
"If we can prevent a problem before it begins," he said, "it's much better than having to see that person six weeks later for an injury which may dampen their enthusiasm for exercise."
Deborah Gesensway is a freelance health care writer in Toronto.
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
While preparticipation screening exams (PPE) are notoriously inefficient in finding that rare person who may succumb to sudden athlete death, the exams are quickly becoming a regular part of summer work for physicians.
The main purpose of these exams is to clear athletes to play sports. They are required for high school and college athletes by nearly every state, the National Collegiate Athletic Association and the National Federation of State High School Associations.
As internists are increasingly called on to do these exams, some are discovering that they can be highly rewarding. Dealing with young, relatively healthy patients can add variety to an internal medicine practice—and provide opportunities for recruiting new patients.
"In many ways, internists are better prepared [than orthopedic surgeons] because not all the problems athletes face are orthopedic," said John Leddy, MD, program director for the primary care sports medicine fellowship at the State University of New York at Buffalo School of Medicine & Biomedical Sciences. "Athletes get sick. They get mononucleosis. They get rashes and concussions. There are issues with heat and nutrition."
Dr. Leddy, who talked about screening exams at this year's Annual Session, said that while there's very little evidence that doing these tests will uncover a potentially life-threatening problem, such as a hypertrophic cardiomyopathy, it is a great opportunity for preventive medicine. Because this may well be the only time young patients see a physician, internists can use these visits to discuss the full range of preventive medicine topics, from seat belts and birth control to diet and steroids.
Philip H. Cohen, MD, assistant team physician for Rutgers University Sports Medicine in Piscataway, N.J., said he also uses the exam visit to screen for eating disorders, discuss menstrual irregularity in females and deal with other issues that may not seem directly associated with athletics.
"We don't always have time to address all the issues during the PPE itself," he said, "but if concerns arise, we ensure appropriate follow-up and evaluation on an individual basis." He said he also fields many questions about supplements and medications. "Many athletes are interested not only in performance enhancement, but they also want to know what is safe and what won't cause them to inadvertently come up positive on a drug test," he said.
Another key function of the PPE is to evaluate athletes with a preexisting condition and help them safely maximize their athletic performance. "We commonly see people with asthma who are on suboptimal medical regimens," Dr. Cohen added. "By adjusting their regimens, teaching them proper use of their medication and empowering them to take charge of the situation, we enable them to feel better and perform at a higher level."
Because disqualifying an athlete from play because of medical concerns can devastate a young person, Dr. Leddy said physicians must make sure they are up-to-date with the latest thinking and evidence about playing sports with medical conditions.
"You should know what to look for and when you should be restricting someone," he said, "and just as importantly when you shouldn't restrict someone from participation." Most athletes with high blood pressure, for example, can continue to play sports, especially if the sport is predominantly dynamic or aerobic.
The same holds true for athletes with a well-controlled seizure disorder. Dr. Leddy cautioned, however, that internists should consult with a neurologist if the athlete wants to participate in higher-risk sports, such as diving, gymnastics or skiing. And athletes with poorly-controlled seizures "shouldn't participate until medication restores control."
ACP debuts new sports medicine book
This summer, the College is publishing its latest addition to its ACP Expert Guides Series: "Expert Guide to Sports Medicine."
The book is designed to help the non-specialist manage sports injuries, with practical guidance on diagnosis, treatment and referral. The book also examines the full range of related clinical challenges—including asthma, cardiac conditions and wound healing—in sports medicine. It also contains a preparticipation screening exam form.
The 496-page softcover costs $32 for ACP members, $35 for nonmembers. You can order it online or from ACP Customer Service at 800-523-1546, ext. 2600. Refer to product #330351000.
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