Treat the patient not the picture“if you hear hooves in the garden, it may be a zebra”

Dr. Conor O BrienFACSM FFSEM FFSEM(uk) FRCPI

CONTENT OF WEBINAR

• Nerve injuries in sport

• PRP• CONCUSSION• DRUGS IN SPORT

Nerve injuries in sport

• 15% surgical• 85% 0veruse injuries• 7% nerve injuries

• Entrapment neuropathies very common in clinical practice

• 19% of runners complained of heel pain

•

Many common injuries are mimicked by nerve injuries

Plantar fashiitis

• Footballers Groin

• Cervical radiculopathy

• TTS

• Pudendal neuropathy

• Ulnar neuropathy at the wrist

Musculoskeletal injuries mimicked by nerve injuries

• MSK • NERVE INJURY

Tarsal Tunnel Syndrome

Tarsal tunnel syndrome (TTS), also known as posterior tibial neuralgia, is a compression neuropathy and painful foot condition in which the tibial nerveis compressed as it travels through the tarsal tunnel 

This tunnel is found along the inner leg behind the medial malleolus .

The posterior tibial artery, tibial nerve, and tendons of the tibialis posterior, flexor digitorum longus, and flexor hallucis longus muscles travel in a bundle through the tarsal tunnel.

Inside the tunnel, the nerve splits into three different segments. One nerve (calcaneal) continues to the heel, the other two (medial and lateral plantar nerves) continue on to the bottom of the foot. The tarsal tunnel is delineated by bone on the inside and the flexor retinaculum on the outside.

• Shooting pain in the foot

• Numbness

• Tingling or burning sensation

• Heel pain mimics PF

• History of ankle trauma

TARSAL TUNNEL SYNDROME

Tarsal Tunnel Syndrome

• An unrecognised cause of foot pain

TIBIAL NERVE ANATOMY

Tarsal Tunnel Syndrome“CTS of the foot”

Patients with TTS typically complain of numbness in the foot radiating to the big toe and the first 3 toes, pain, burning, electrical sensations, and tingling over the base of the foot and the heel.

Depending on the area of entrapment, other areas can be affected. If the entrapment is high, the entire foot can be affected as varying branches of the tibial nerve can become involved. Ankle pain is also present in patients who have high level entrapments

Branches of the tibial nerve: anatomic variations.T J Davis, L C Schon

Department of Orthopaedic Surgery, Union Memorial Hospital, Baltimore, Maryland, USA.

Foot & Ankle International 

Anatomic variations in tibial nerve branches may help explain discrepancies between clinical examination and standard electrophysiologic tests as to the location of neuronal lesions. Dissection of 20 cadaveric feet (10 pair) along the course of the tibial nerve and its branches confirmed that it bifurcates within 2 cm of the medio-malleolar-calcaneal axis in 90% (18/20)

The tibial nerve gives off frequent small branches with its accompanying vascular structures.

Study found that 60% had multiple calcaneal branches off the tibial nerve and that 20% evidenced previously undescribed accessory innervation to the abductor hallucis muscle from other than the medial plantar nerve.

Baxter`s Neuropathy

Medial view of the ankle with the abductor hallucis partially removed depicting the posterior tibial nerve (PTN) branches. After giving off a small medial calcaneal nerve branch (MCN), the PTN bifurcates into the medial (MPN) and lateral (LPN) plantar nerves within the tarsal tunnel. The first branch of the LPN is Baxter's nerve also known as the inferior calcaneal nerve (ICN)

Baxter`s Neuropathy“resistant plantar fasciitis”

• Baxter's nerve, or the first branch of the lateral plantar nerve,• typically branches off just proximal to the abductor hallucis muscle.

• As Baxter's nerve descends deeper into the foot,• it passes through a portal referred to as the porta pedis or 'window to the

foot'.

• The porta pedis is a well known location for each of the nerves that pass through this portal to become entrapped.  Additional areas of entrapment for Baxter's nerve include the region deep to the plantar fascia.

• As Baxter's Nerve reaches the plantar aspect (bottom) of the abductor hallucis muscle, the nerve turns to the lateral aspect of the foot and passes anteriorly and medial to the calcaneus (heel bone). This location is known as the calcaneal tuberosity and is the location where a heel spur may form. Baxter's nerve continues laterally between the quadratus plantae and flexor brevis muscles to its' insertion into the abductor digiti minimi muscle.

Baxter`s form of TTS

• Baxter's nerve entrapment refers to an entrapment of the calcaneal branch of the posterior tibial nerve.  Baxter's nerve entrapment is a differential diagnosis that should always be considered when treating heel pain. Although plantar fasciitis is a much more common cause of plantar heel pain, astute clinicians will always include Baxter's entrapment in a complete clinical workup for heel pain.

• Baxter first described this condition in 1984. Baxter proposed that the first branch of the lateral plantar branch of the posterior tibial nerve would become entrapped in the medial heel. The entrapment would result in heel pain and numbness of the plantar aspect (bottom) of the heel.

• Diagnosing Baxter's nerve entrapment requires a high degree of clinical suspicion.

• EMG to the abductor digiti quinti

Prior Neurophysiology ELECTRODIAGNOSTIC TECHNIQUES IN TTS EVIDENCE-BASED REVIEWPATEL ET AL 2005 MUSCLE AND NERVE 32: 236-240,2005

Variable assessment parametersUsefulness for confirming diagnosis Level CMeeting Class 3 of evidence• Sensory studies alone• Motor studies alone• +/- EMG

HISTORY OF ASSESSMENTMayer initially reported Normal values for tibial nerve motor latencies in 1963Guiloff and Sherratt published normal values for the medial plantar sensory study to the Great Toe in 1977

ANATOMYBaxter identified that the nerve to ADQ was the first branch of the lateral plantar nerve 19849 different branching patterns of the tibial nerve at the Tarsal Tunnel have been identified 2009

Available tests

NERVE CONDUCTION STUDIES1. Tibial Motor to AH2. Lateral Plantar sensory study3. Medial Plantar sensory study4. Calcaneal sensory study5. Combined Sensory Index The sum of the disal latencies of 2,3 & 4 Versus Saphenous , S Peroneal, Sural d l.(0.9 ms 9 upper limit of normal)

EMGAdductor HallucisAbductor Digiti Quinti Quadratus Planae

ULTRASOUNDexamination of the nerve cross sectional areaTibial nerve at TTS 12MM sq or less

• Clinical Examination• Neurophysiological

assessment• Radiology for masses

• In a series of 40 patients seen at SSC

• 90% had a history of previous ankle injury or lower limb surgery

Most Commonly positive tests• Calcaneal sensory• Needle EMG • Two tests which were not

previously routinely performed• In a majority of cases a

combination of positive findings existed

Diagnosis of TTS

TTS Rx

• Treatment “ direct “ “double crush”• NSAIDS• Orthotics• Injection under u/s guidance

SURGERY fewer than 50% of the patients reported improvement, and there was a 13% complication rate.

This is a staggering percentage of complications for what is a fairly superficial and minor surgical procedure.

Tarsal tunnel can greatly impact patients' quality of life. Pfeiffer 1996

• 44% surgical success rate• 13% surgical side effect • Steroid injections• Steroid and local

anaesthetic injections• Hydro-discetion• PRP injections

• Ultrasound and EMG guidance

Non surgical treatment

BIKE RIDINGBetween 2006 and 2011 [nationally] there was a 9.6 per cent jump in the number of persons cycling, rising from 36,306 to 39,803. [This figure is just for workers, another 21,374 cycle to school or college]However, close to 20,000 fewer persons cycled to work in 2011 compared with 1986, when the number of cyclists was at its peak. The share of commuters cycling to work was 2.4 per cent at the last census, as opposed to 7.2 per cent recorded in 1986.

Pudendal Neuropathy

Both gendersFocal compressionPerineal descentPelvic surgeryMedical conditions

John Hilton 1863Describes a pain “it was quite apparent the cause was associated with the perineal branch of the PUDIC NERVE, the patient was cured by removing pressure from the nerve, by cutting a hole in his seat and the use of a hollowed out cushion”Hilton J. Rest and Pain .Bell and son. 5th ed 1918

• Pudendal Nerve

BIKE SEAT NEUROPATHY “PUDENDAL NEUROPTHY”

Bike seat neuropathy

What is bicycle seat neuropathy?Bicycle seat neuropathy is a common injury experienced by both male and female cyclists. Symptoms can include temporary numbness or pain in the groin and perineal area (located

between the testicles or vagina and rectum) and even erectile or sexual dysfunction. While most

cases are reversible and temporary, there have been reports of long-term sexual dysfunction in some cyclists who didn’t seek treatment or make changes to their bike position or riding style after the symptoms started.

What causes the symptoms?The symptoms of bike seat neuropathy are caused by the cyclist supporting his or her body

weight on a narrow bike seat, and are related to temporary and transient ischemic compression of the pudendal nerve between the bicycle seat and the pelvic bones. Bicycle seat design and

shape also appears to be a major factor in the development of bicycle seat neuropathy. Computer modeling studies of various bike seat shapes demonstrated that wider bicycle seats that support

the ischial tuberosities (the sit bones) decrease pressure on the perineal area.

“Bike Seat” Pudendal Neuropathy

The incidence of bicycle seat neuropathy is believed to be underreported. A study of symptoms reported by cyclists participating in a 500-mile bicycle tour found that:

45% of the participating cyclists reported at least mild and transient perineal numbness, with

10% reporting the symptoms as severe, and2% of the cyclists with symptoms severe enough to force them to temporarily stop riding.

Another study surveyed 260 cyclists participating in a 330 mile long bike tour. The researchers found that of the responding males,

22% reported symptoms of either numbness or pain in the pudendal area.

Additionally, 13% of male cyclists reported symptoms of impotence, including 11 of whom experienced symptoms for longer than one week, and three of whom reported impotence lasting longer than one month.

Bicycle seat neuropathy has also been documented in women cyclists. A study of 282 female members of a Dallas

cycling club found that 34% of the women reported perineal numbness related to cycling on at least one occasion.

Pudendal nerve

Pelvic floor dysfunction

• Pudendal neuropathy

• Gynaecology• 1/3 of patients• Prostate surgery• Lumbar spine

Disease• SYMPTOMS• Pelvic floor pain• Flatus incontinence• Faecal incontinence• Urinary incontinence• Sexual dysfunction

• Combination of all 5

TreatmentLike all overuse in juries

IntrinsicExtrinsic causesTreatment of the INJURY

Target the therapyIntrinsic RxNeuropathic painIncontinence Sexual dysfunction

Extrinsic RxThe main treatment for bicycle seat neuropathy is the adjustment of the bike seat and proper bike position, which may include tilting the nose of the seat down or lowering the seat height to relieve pressure from the perineum. Other recommendations include having the rider change the style of riding, such as frequently stopping or changing riding positions. Sometimes decreasing training volume can also help alleviate symptoms.

Ultrasound of the pudendal nerve

• Located beside the pudendal artery, and between the sacrotuberous and sacrospinus ligaments.

• Bony land mark ischial spine

Guyon`s Canal Syndrome

      Guyon (French Urologist) described this space in 1861;    

Guyon's canal is approximately 4 cm long beginning at the proximal extent of transverse carpal ligament and ends at the aponeurotic arch of hypothenar muscles;  

Depression between pisiform & hook of hamate is converted into fibrosseous tunnel, the tunnel of Guyon, by pisohamate ligament;    Roof is formed by volar carpal ligament and pisohamate ligament; the ulnar nerve bifurcates within the canal into superficial and deep branches; Deep branch of the ulnar nerve (more radial) and superficial branch more ulnar    tunnel of Guyon is clinically significant because it contains ulnar nerve and artery & is site for compression injury;           ; 

Cyclist Palsy Ulnar neuropathy at

GUYON`S CANAL

  - zone 1 compression:           - extends from the proximal edge of the palmar carpal ligament to the bifurcation of the ulnar nerve           - compresses sensory and motor aspects of the ulnar nerve as well as the motor innervation of the hypothenar muscles

   - zone 2 compression:           - extends from the bifurcation of the ulnar nerve just distal to the fibrous arch of the hypothenar muscles           - the deep motor branch of the ulnar nerve is susceptible to compression;

   - zone 3 compression:           - contains the superficial sensory branch of the ulnar nerve;

GUYON`S CANAL

Cyclist palsy

• Ulnar neuropathy at the wrist

• In association with CTS or in isolation

• Mimics C8 cervical radiculopathy

Cyclist palsy with CTS2 CASES IN PAST 6 MONTHS

Elite cyclist bilaterally

Recreational cyclist on cousins bike for weight loss

Treatment of cyclist palsey

• INTRINSIC AND EXTRINSIC THERAPIES

AUTOLOGOUS PLATLET RICH PLASMA

• New therapeutic option• Promotes healing by promoting an inflammation response

• Platelet-rich plasma ( PRP) is blood plasma  that has been enriched with platelets.

• As a concentrated source of autologous platelets, PRP contains ,and releases through degranulation, several different growth factors and other cytokines that stimulate healing of bone and soft tissue

“Degranulation” is a cellular process that releases antimicrobial cytotoxic molecules from secretory vesicles called granules found inside some cells. It is used by several different cells involved in the immune system, including granulocytes (neutrophils, basophils and eosinophils) and mast cells

Platelet rich plasma injections

Musculoskeletal Medicine• All Connective Tissue's have three

elements: fibers, cells, and non-cellular matrix material. Collagen is the most common fiber

•Platelet rich plasma injections (PRP injections) can be used in the treatment of many musculoskeletal injuries including that of tendons, muscles and joints.

• Promotes a healing [inflammatory response] to produce collagen Type1

• Almikinders 1993 showed that NSAIDS promoted the formation of collagen Type 2

PRP promotes an inflammatory response

Clinical uses of PRP injections

PRP injections aim to embrace and stimulate the inflammatory process which in turn will encourage the healing process.

PRP focuses on restoring normal tissue composition while avoiding further

degeneration. 

TENDONTennis elbow (common extensor tendinosis)Golfer’s elbow (medial epicondylitis)

Jumper’s knee (patellar tendinosis)

Achilles tendinosis 

Plantar fasciitis

Hamstring tendons

Adductor tendons

Gluteal tendons

MUSCLEHamstringCalfQuadriceps

OTHERSTrochanteric bursitis

Knee MCL tears

Knee osteoarthritis

Hip Osteoarthritis

PRP RESEARCH

Filardo G, Kon E, Buda R, Timoncini A, Di Martino A, Cenacchi A, Fornasari PM, Giannini S, Marcacci M. Platelet-rich plasma intra-articular knee injections for the treatment of degenerative cartilage lesions and osteoarthritis. Knee Surg Sports Traumatol Arthrosc. 2011 Apr;19(4):528-35. Epub 2010 Aug 26.

Gosens T, Peerbooms JC, van Laar W, den Oudsten BL. Ongoing Positive Effect of Platelet-Rich Plasma Versus Corticosteroid Injection in Lateral Epicondylitis: A Double-Blind Randomized Controlled Trial With 2-year Follow-up. Am J Sports Med. 2011 Jun;39(6):1200-8.

Wang-Saegusa A, Cugat R, Ares O, Seijas R, Cuscó X, Garcia-Balletbó M. Infiltration of plasma rich in growth factors for osteoarthritis of the knee short-term effects on function and quality of life. Arch Orthop Trauma Surg. 2011 Mar;131(3):311-7. Epub 2010 Aug 17.

Kon E, Buda R, Filardo G, Di Martino A, Timoncini A, Cenacchi A, Fornasari PM, Giannini S, Marcacci M. Platelet-rich plasma: intra-articular knee injections produced favorable results on degenerative cartilage lesions. Knee Surg Sports Traumatol Arthrosc. 2010 Apr;18(4):472-9. Epub 2009 Oct 17.

PRP THERAPY

PRP

AUTOLOGOUS PLATLET RICH PLASMA

• PlateletsMediate cell to cell adhesion through the release of various adhesion molecules and growth factors• Growth FactorsPDGF [ chemoattractive for stem cells and endothelial cells]TGF beta [ differentiation of connective tissue and bone]VEGF [angiogenesis]• White Blood CellsPrimarily mononuclear, not granulocytes• Cytokines & Adhesion MoleculesSDF-1alpha[ modulates migration and homing of stem cells to repair site]

ConcussionA concussion is a traumatic brain injury that alters the

way your brain functions.

Concussion

• Concussion and sport BMJ ,Conor O`Brien14 November 2013• Many"tools" available to assist in the diagnosis and assessment of sports concussion, incorporating both physical and

cognitive assessment. These fail to incorporate the first principles of medical assessment, namely history and

examination followed by appropriate test.• The history of the injury is probably the most critical element in assessing a case of concussion. The history of a head injury

leading to concussion will often be observed by a pitch side doctor, who may have witnessed the trauma.

• The over reliance on an assessment tool can also dumb down the doctor patient consultation, and may leave a player vulnerable to being returned to play on the basis of a test,which may be administered by a non medic, and often carries more weight in the heat of a competitive football match, than the clinical experience of a pitch side medical practitioner`s opinion.

• Time for doctor to arrive to injured is on average 18 seconds, and is nearly always more than 10 seconds. The rationale being that this is the time frame for a boxing match to be terminated following a "knock out".

• Once a concussion has taken place, the brain becomes more vulnerable to a second concussion which is potentially catastrophic. Hence the need for caution and consideration when returning a player back to the field of play.

• When returning an individual to sport after a concussion further care must be taken. Medical investigations, such as Brain MRI and Neurophysiology investigations will fail to identify all brain injuries, and may only become positive late in the process.

• The clinical history of symptoms often gives the greatest information, as the neurological examination is usually normal. Similarly cognitive testings are non specific, and can be "foxed" by a player who wishes to return to play, by posting a poor score in preseason testing.

• Over reliance on a test does not serve the injured well. It does however give a sense of security to a sports team, who wish to get "their man, back on the pitch".

Special Tests for Pitch side and office assessment of

ConcussionSAC Standard Assessment of Concussion

BESS Balance Error Scoring System

King- Devick Vision Test

Usually, there is no evidence of structural brain abnormalities immediately after a concussion, but the researchers found that there was measurable brain atrophy one year after a concussion.

Specifically, there was significant atrophy in the white matter of the anterior cingulate and cingulate gyrus isthmus brain regions.

The anterior cingulate is important for many complex neuronal systems, including mood, attention, working memory, and executive function, all of which are frequently abnormal after a concussion.

The cingulate gyrus isthmus helps regulate anxiety, as dysfunction of the cingulum has been implicated in several psychological disorders, including schizophrenia.

Zhou Y., Kierans A., Kenul D., Ge Y., Rath J., Reaume J., Grossman R.I. & Lui Y.W. Mild Traumatic Brain Injury: Longitudinal Regional Brain Volume Changes, Radiology, DOI: 10.1148/radiol.13122542

Giza C.C., Kutcher J.S., Ashwal S., Barth J., Getchius T.S.D., Gioia G.A., Gronseth G.S., Guskiewicz K., Mandel S., Manley G. & McKeag D.B. Summary of evidence-based guideline update: Evaluation and management of concussion in sports: Report of the Guideline

Development Subcommittee of the American Academy of Neurology, Neurology,

Brain atrophy associated with Concussion

concussion

Concussion

• History examination and special tests if required

• Sports Medicine First Aid has been thought to generations of

doctors using the Pneumonic P.R.I.C.E.S., where P stands

for "protect the player from doing further harm."

• The current vista of clearly injured players returning to the

field, flies in the face of this old medical axiom.

• If team doctors are compromised in making clinical decisions,

then an independent means of assessing the concussed must

be sought, both at the time of injury, and when the player

wishes to return to play..

• INDEPENDENT MEDIC? 

This problem of unrecognized concussion has been

highlighted in a recent publication relating to American

Football which describes how the National Football League

failed to deal with the clear scientific evidence relating to NFL

concussions and brain injury.

The NFL ultimately settled a costly law suit brought by

thousands of former American Football players, who suffered

long term morbidity from brain injuries which occurred during

their football careers{3}.

Further research has suggested a higher than expected

incidence of chronic traumatic encephalopathy in

pathology specimens of the brains of ex NFL players[4].

Drugs in Sport

Drugs in Sport

To day the world of sport is full of drug scandals

• Lance Armstrong• Frankie Detorrie• Australian Rugby League• American Baseball• Spanish Football &Tennis• Italian Football• Kenyan Athletics• Jamaica Athletics• Professional Golf• Horse racing• Oscar Pistorius

“roid rage” potential cause in wrestler's murder-suicideEx-star Benoit killed wife, son, self in grisly crime spread out over weekend

• Chris Benoit, born in Montreal, was a former world heavyweight champion, Intercontinental champion and held several tag-team titles. His names in the ring included “ The Canadian Crippler.”

• FAYETTEVILLE, Ga. - Pro wrestler Chris Benoit strangled his wife, suffocated his 7-year-old son and placed a Bible next to their bodies before hanging himself with a weight-machine pulley, authorities said Tuesday.

• Investigators found anabolic steroids in the house and want to know whether the muscle man nicknamed “The Canadian Crippler” was unhinged by the bodybuilding drugs, which can cause paranoia, depression and explosive outbursts known as “roid rage.”

• Authorities offered no motive for the killings, which were spread out over a weekend, and would not discuss Benoit’s state of mind. No suicide note was found.

The British crime survey 1996 and 2000

“A society problem not just sport”• 1% of male and 1% of

female arrestees between the ages of 16 and 59 had used AAS. Highest use among the 20-24 year old males [3%] [1996]

• 1% of all arrestees had used AAS in the previous year and 5% of the 17-25 years olds had taken them [2000]

• A SOCIETY PROBLEM

Compared with 10 years ago: Between 2002 to 2003 and 2012 to 2013

Increase Decrease No change

Anabolic steroids

Any drug Powder cocaine

  Any stimulant drug

Crack cocaine

  Any Class A drug LSD

  Ecstasy Heroin

  Magic mushrooms

Methadone

  Amphetamines Tranquillisers

  Cannabis  

  Amyl nitrite

British Crime Survey

Drugs in Sport

Over the past 2 decades assessment of over the counter

and internet bought sports supplements have shown that

a significant percentage are contaminated.

Figures as high as 23% in the early 1990`s and a 2013

survey of European Supplements showed a 10%

contamination rate in a sample of 114 products.

(3) Contamination was caused by a variety of agents

including anabolic steroids, growth hormone, the pill and

peptide hormones all of which can result in

compromising side effects. Therefore the potential

miracle sports supplement may in fact be deleterious to

the vulnerable athlete’s health.

“Roid Rage” controversial entitywhat`s the evidence?

• 1980 Roid Rage

• 1996 Mood swings associated with ASS use BMJ

• 2000 600mg testosterone/week increased manic and aggressive scores

• 2005 “significant psychiatric symptoms including aggression, violence ,mania, psychosis and suicide have been associated with steroid abuse”

• 2005 Hypomania and aggressiveness associated with AAS• Hypomna is a mood state characterized by persistent disinhibition and pervasive elevated (euphoric) or irritable mood.

• 2006 AAS psychiatric side effects is correlated to severity

• 2008 Violent acts and AAS (USA young males)

Behavioral Neuroscience 2006

• If you put a hamster on steroids, he'll attack other hamsters more quickly and more often, and bite a lot. Cut him off and you might think he'd mellow out.

• Not so. Hamsters on steroids remain aggressive into adulthood, according to a study that offers yet another caution to teens who might try to bulk up artificially.

• The National Institute on Drug Abuse, about half a million teens abuse anabolic-androgenic steroids.

• Other research has shown teen use can lead to psychiatric problems and heavier steroid use later in life

• Autopsies revealed their brains had changed. The anterior hypothalamus, known to regulate aggression, pumped out more of a neurotransmitter called vasopressin.

• "Steroids step on the gas for aggression by enhancing the activity of brain areas that induce aggression,“

• this brain area is similar in rodents and humans.

• "Some of the effects may wear off after withdrawal, but aggressive behavior won't stop immediately, leaving them to be a danger to themselves and others."

National Institute of Drug Abuse July 2012

• How Do Anabolic Steroids Affect the Brain?• Anabolic steroids work very differently from other drugs of abuse, and

they do not have the same acute effects on the brain. • The most important difference is that steroids do not trigger rapid

increases in the neurotransmitter dopamine, which is responsible for the rewarding “high” that drives the abuse of other substances.

• However, long-term steroid use can affect some of the same brain pathways and chemicals—including dopamine, serotonin, and opioid systems—that are affected by other drugs, and thereby may have a significant impact on mood and behavior.

• Abuse of anabolic steroids may lead to aggression and other psychiatric problems, although many users report feeling good about themselves while on steroids,

• Violent mood swings can also occur, including manic-like symptoms and anger (“roid rage”) .

• Researchers have also observed that users may suffer from paranoid jealousy, extreme irritability, delusions, and impaired judgment stemming from feelings of invincibility.

Questions/Critiques