James G. Macintyre

Stress fractures in athletes: A study of 320 cases

We analyzed cases of 320 athletes with bone scan- positive stress fractures (M = 145, F = 175) seen over 3.5 years and assessed the results of conservative management. The most common bone injured was the tibia (49.1 %), followed by the tarsals (25.3%), metatar sals (8.8%), femur (7.2%), fibula (6.6%), pelvis (1.6%), sesamoids (0.9%), and spine (0.6%). Stress fractures were bilateral in 16.6% of cases. A significant age difference among the sites was found, with femoral and tarsal stress fractures occurring in the oldest, and fibular and tibial stress fractures in the youngest. Run ning was the most common sport at the time of injury but there was no significant difference in weekly running mileage and affected sites. A history of trauma was significantly more common in the tarsal bones. The average time to diagnosis was 13.4 weeks (range, 1 to 78) and the average time to recovery was 12.8 weeks (range, 2 to 96). Tarsal stress fractures took the longest time to diagnose and recover. Varus alignment was found frequently, but there was no significant difference among the fracture sites, and varus alignment did not affect time to diagnosis or recovery. Radiographs were taken in 43.4% of cases at the time of presentation but were abnormal in only 9.8%. A group of bone scan- positive stress fractures of the tibia, fibula, and meta tarsals (N = 206) was compared to a group of clinically diagnosed stress fractures of the same bone groups (N = 180), and no significant differences were found. Patterns of stress fractures in athletes are different from those found in military recruits. Using bone scan for diagnosis indicates that tarsal stress fractures are much more common than previously realized. Time to diagnosis and recovery is site-dependent. Technetium99 bone scan is the single most useful diagnostic aid. Conservative treatment of stress fractures in athletes is satisfactory in the majority of cases.

Scintigraphic Uptake of 99mTc at Non-Painful Sites in Athletes with Stress Fractures

SummaryStress fractures are commonly found in athletes attending sports medicine clinics for diagnosis of lower limb pain. Plain radiographs are less reliable than the 99mTc bone scan for diagnosing stress fractures because of their low sensitivity. While the heightened sensitivity of the bone scan is advantageous as a diagnostic aid, the uptake of99mTc at non-painful sites occurs frequently in the athlete. Although the clinical significance has not been determined, asymptomatic uptake may indicate bone remodelling as part of a continuum of adaptation to physical stress. It is not known whether athletes who have uptake of99mTc in asymptomatic areas represent a separate population from those who do not. This study retrospectively reviewed the medical charts and bone scan reports of 320 athletes diagnosed as having stress fractures, to determine the frequency of asymptomatic focal uptake at sites other than the site of pain. This group was compared with the group who had no asymptomatic uptake on a number of demographic variables and physical findings. Asymptomatic focal uptake was found in 37.5% of athletes with the average number of sites being 1.8 per person. No significant differences between groups with focal asymptomatic uptake and groups with no asymptomatic uptake were found when compared4 for age, height, weight, mileage in runners, times to diagnosis and recovery, frequency of tenderness, swelling, trauma history, varus alignment, and x-ray abnormalities. It is concluded that asymptomatic uptake of99mTc occurs frequently in athletes with stress fractures and there are no significant clinical differences between the group with asymptomatic uptake and the group without. It is suggested that symptomatic uptake of99mTc represents the remodelling response of bone to physical stress.

Running Injuries: A Clinical Study of 4,173 Cases

This retrospective study reports on 4,173 running injuries seen on referral over a 4-year period at a sports medicine clinic. Runners were grouped as recreational, marathon, or middle distance runners on the basis of their training, and data was examined for groupwise differences in age, gender, anatomical site of injury, diagnosis, and time of year the injury presented. Additionally, the results were compared to those of a 1981 study of 1,819 injuries from the same population in order to determine changes in injury patterns over time. The knee was the most common site of injury, with patellofemoral pain syndrome the most common overall diagnosis, although there were significant differences between the training groups for both injury site and diagnosis. The pattern of injuries has changed over the interval between the two studies, with a higher proportion of knee injuries and a relatively lower frequency of lower leg and foot injuries, and much of this change is attributed to improvements in footwear technology.

Growth hormone and athletes

SummaryGrowth hormone is a powerful anabolic hormone that affects all body systems and plays an important role in muscle growth. It is released from the anterior pituitary in response to a variety of stimuli including exercise, sleep, stress, and the administration of a variety of drugs and amino acids. Serum levels are variable and are dependent on such factors as age, sex, body composition and level of fitness. Animal experiments have shown that growth hormone can partially reverse surgically induced muscle atrophy and weakness. Growth hormone administration to normal animals leads to muscle hypertrophy, but this muscular growth is not accompanied by increased strength. Growth hormone excess leads to acromegaly, a disease with significant morbidity, including a myopathy in which muscles appear larger but are functionally weaker. Although there is no scientific evidence documenting an improvement in athletic performance following growth hormone supplementation, it is reported that this practice is becoming more widespread among athletes wishing to avoid detection with current doping control measures. There are anecdotal reports that athletes are injecting cadaveric or biosynthetic forms of growth hormone, both of which are associated with potentially serious complications. In addition, some athletes are ingesting drugs and amino acids in the belief that their endogenous growth hormone secretion will be increased. There have been no scientific studies on the effects of growth hormone supplementation, and the anecdotal reports have been equivocal, with some individuals reporting spectacular results while others report no change. Despite the lack of valid evidence for its efficacy and its potentially serious side effects, it has been predicted that growth hormone use may increase. Growth hormone use and abuse has the potential to dramatically change the future conduct of athletics and may prove to be a threat to the concept of fair competition.

Sports medicine practice economics part 2: consultations, modifiers, and other codes.

Physicians face numerous challenges related to sports medicine practice economics, including coding and billing for consultations. Some of this difficulty stems from a lack of widespread recognition of sports medicine as a specialty. To further complicate matters, many insurance companies refuse to recognize dual credentials in both family medicine and sports medicine. Physicians can better position themselves for appropriate reimbursement from third-party payers by becoming familiar with modifiers and related codes for various sports medicine services, including fracture care, injections and arthrocentesis, and osteopathic mobilization.

Exercise Training Improves Elderly Muscle Function

Treatment of isolated displaced fractures of the medial humeral epicondyle in children is controversial. Nonsurgical treatment for fractures with 5to 15-mm displacement yielded long-term results similar to those obtained with open reduction and internal fixation, according to a long-term retrospective study. Forty-two children (average age, 12) who had a medial humeral epicondylar fracture were grouped according to their treatment. Group 1 (19 patients) had been treated nonsurgically (long arm cast). Group 2 (17 patients) had had open reduction and internal fragment fixation, then a cast. Group 3 (6 patients) had excision of the osteocartilaginous fragment with tendons and medial collatera! ligament sutured to the adjacent periosteum before cast application. The authors suggest that nonsurgical treatment yielded long-term results comparable to those of open reduction and internal fixation and that surgical excision should be avoided because ofits poor long-term results.

Lower leg varum alignment in skiing: relationship to foot pain and suboptimal performance

In brief: Varum alignment of the lower leg can produce problems that may affect a skiers performance and lead to foot pain. Technological advances in ski boots now make it possible to compensate for tibia vara through cuff adjustments, and in-the-boot orthotic devices with forefoot and rearfoot posting can help to correct the problems caused by an excessive degree of varum alignment of the lower leg. These corrections can help the skier to ride a flat ski during gliding and maintain proper body position while edging during turning. In this article, the authors discuss skiing technique, ways to measure a skiers varum alignment, and methods of compensating when malalignment interferes with proper technique or causes foot pain.

Sports Medicine Practice EconomicsPart 1: Coding Basics

Proper understanding of coding, billing, and other practice economics issues in sports medicine is vital for practice success. Lack of accuracy and understanding in these areas may lead to problems that range from lost income to practice audits and potentially steep fines. A basic understanding of current procedural terminology (CPT), awareness of international classification of diseases (ICD-9) and healthcare common procedure coding system (HCPCS) codes, and the knowledge of how to apply them benefit sports medicine physicians.

Sports medicine practice economics part 3: billing, collecting, appeals, and related tasks.

Knowledge about proper coding in sports medicine will not benefit a physician or his or her practice if bills submitted to insurance companies are not regularly monitored and analyzed for trends. Physicians can help ensure successful collections by understanding the dynamics of reimbursement, enlisting the efforts of office colleagues, and facilitating patient involvement when appropriate.

Sports medicine practice economics part 1: coding basics.

In Brief Proper understanding of coding, billing, and other practice economics issues in sports medicine is vital for practice success. Lack of accuracy and understanding in these areas may lead to problems that range from lost income to practice audits and potentially steep fines. A basic understanding of current procedural terminology (CPT), awareness of International classification of diseases (ICD-9) and healthcare common procedure coding system (HCPCS) codes, and the knowledge of how to apply them benefit sports medicine physicians.