S4E1: A Tri-oww-thalon of injuries - Sports Medicine
Welcome back to a brand new season of TheCase.Report! As we continue to grow into our fourth season, so too does our team - a big welcome to our many new members who are taking TCR to new heights. The team have been working all throughout our summer hiatus to deliver what promises to be an incredibly exciting season 4! Many thanks as always to IAEM who make this podcast possible - at our heart, we are a community of learning and it is humbling to see how the podcast has evolved over time. But enough of the soppiness, we’re starting the season as we mean to go on - with a bang. Literally.
We’re kick starting this new TheCase.Report marathon with the golden triad - Leah, Liam and Carl.... oh and also swimming, cycling and running. It’s triathlon time! Treating you to a trio of interesting cases, increasingly relevant to EM, we’re delving into some presentations to watch out for, how to manage them and tips to keep your patients off the bench.
Coaching us through it we have our Adult in the Room, Patrick Martin. Paddy is one of our amazing Emergency Advanced Nurse Practitioners and we are very lucky to have us join us this month. Don’t forget to download the incredible infographics that accompany the show notes made by our fantastic new junior producers!
Now let’s get in on the action!
Case 1: Troubled Waters
A 28-year-old female presents to the Emergency Department the day after beating her personal best in Dublin’s EM Triathlon with 5 episodes of diarrhoea overnight, abdominal cramps, nausea, one episode of vomiting and general weakness. She went straight home afterwards without celebrating that night.
History and exam
Getting a good history is going to be key to narrowing down a diagnosis here. Delve into the specifics of the event - this may involve a bit of googling about what’s involved if you aren’t a sports guru. There are various types of triathlon from sprint, to mini-triathalon, to ironman. The varied activities of the event may be relevant here - What events were involved? What distance was each event? Is there a possibility water was ingested - and if so, was it a river, lake, ocean etc? If you aren’t familiar with specific sports medical complaints, don’t be afraid to ask a senior! It’s likely there is someone there in the department who can help you out.
Given the history, an assessment of hydration status is vital here. And on the topic of vitals, be cautious with interpreting tachycardia in athletes as they may have a very low baseline rate. A borderline tachycardia may be an incredibly high HR for an athlete.
Tip: if an athlete voices concern that their heart rate is abnormally high this should ring a little alarm bell and make you cautious.
Think horses not zebras. Unless they’re sick zebras.
We’re primed in EM to rule out the most life threatening things first. Once that’s done, common things being common here, our top concerns include gastroenteritis, rhabdomyolysis, electrolyte disturbance, dehydration, and they aren’t mutually exclusive. Thus don’t omit the essentials of your history - asking about sick contacts, recent travel, b symptoms etc. will assist in narrowing down the diagnosis. Don’t forget a high CK may be normal post a prolonged endurance event; look out for the classic triad of rhabdomyolysis: myalgia, weakness and myoglobinuria. If you aren’t sure, don’t be afraid to ask a senior.
Gastroenteritis
These 3 words will help you beyond belief in your management of patients with gastroenteritis: rehydration, rehydration, rehydration (I’ll let you argue in the comments whether this is one word or three). Where possible it’s best to correct the dehydration with oral fluids, but as we saw in our case, it may be necessary to give some IV fluids while waiting on anti-emetics to kick in. In the absence of red flag symptoms, antibiotics should be avoided for gastroenteritis. Electrolytes should be replaced appropriately.
Depending on the clinical status of your patient, it would be wise to send some bloods while the patient is receiving their IV fluids. While a true hyponatraemia is lower down our differential in this patient, a routine set of bloods will allow us to correct the correctable. Leah and Carl had a little chat about antidiarrhoeal agents. Their consensus: they’re only useful if ongoing excessive trips to the bathroom, and the patient is more than 12-years-old.
Wave your flag
Unfortunately, it’s a rare occurrence that a patient attends the department with their own red flag. Cue the “Art of History Taking”. So what exactly do we need to look out for here?
Signs and symptoms which should send alarm bells ringing include fevers or any suggestion of sepsis. Bloody diarrhoea or travellers diarrhoea should prompt consideration of the organism; one could consider fluoroquinolone in these cases. In the case of a suspected campylobacter infection, you could also consider a course of azithromycin.
From red flags to red eyes
If your patient presents with symptoms of gastroenteritis and eye symptoms such as scleral injection or particularly scleral jaundice, they may have more to worry about than avoiding trolleys in the Liffey. Though more common in racing across farmlands, Leptospirosis can be contracted through swimming in contaminated water, and cause Weil’s disease. The CDC in the USA even issue a warning about potential spread of leptospirosis during hurricane season.
Leptospirosis, if allowed to fester, can lead to life threatening injuries and life altering damage to the kidneys and liver. It’s a zebra you do not want to miss. This can be more common in rivers near farmland after heavy rainfall. It usually has a latency period of 1-2 weeks, but symptoms can occur within 2 days. Treatment options include doxycycline. If you ever do come across a case, or suspected case, of it, remember it is a notifiable disease in Ireland and consult your local antibiotic guidelines/infectious disease team for input.
The bottom line: if symptoms are prolonged in gastroenteritis, think of other causes.
And while we didn’t mention it in the episode…
Open water worries
More and more people are getting involved in open-water swimming and other water activities, but how informed are they of the risks involved? A HSE-backed study found that 26.4% of these athletes have suffered from illnesses linked to waterborne disease, but only about 60% had awareness of this risk, while just under 40% had received information on these diseases. Triathletes had the lowest awareness of the study, but were the most likely to accidentally ingest water. Just over 50% of participants would enter the water regardless of the risk of contamination. This highlights the importance of identifying patients who would benefit from water safety education, so that we can help them to limit any adverse impacts from their hobbies.
Save our swimmers
General advice includes swimming in beaches upholding EU bathing standards e.g. Blue Flag beaches. Rivers have the highest risk of contamination and it increases with poor weather conditions. Of course, avoiding ingestion of water where possible will decrease a swimmers’ chance of contracting a disease, and on exiting water; hand hygiene before eating/drinking, shower as soon as possible, and cleaning equipment all reduce the chances of swimmers becoming ill.
Case 2: Tour de l’Emergency Department
A 32-year-old man presents with a 3 day history of sensory changes and progressive weakness to the ulnar edge of his right hand, his little finger and his ring finger. Wrist flexion exacerbates his symptoms, as do activities such as cycling his beloved bike.
History and exam
A SOCRATES history will, as always, help to elicit the aetiology of this man’s pain. Previous occurrences of these symptoms, relieving factors and a deeper dive into how long these symptoms have been present for are all relevant here. It’s also necessary to define the extent of sensory changes. A neurological examination will lead you in the right direction, but given the predominant deficit is sensory, asking targeted questions such as whether there is any involvement proximally or to other regions of the hand, sensory disturbances in the rest of his body, or specific trauma (recent or past) will guide your diagnosis before even performing an exam.
On examination the aim is to assess extent of sensory changes, any weakness or involvement of other areas not identified in the history and any other positive findings not identified by the patient. Thinking in terms of nerve root coverage and dermatomal coverage can help you in your differential and diagnosis. In this case, we found altered sensation in the ulnar border of his right hand to wrist and little and ring fingers, notably provoked by hyperextension. Examination of the proximal median and radial nerves is normal.
Distal Ulnar Palsy (DUP)
This man experienced symptoms of altered sensation and weakness in the ulnar region of his hand on longer distance bike rides which worsened with hyperextension, settled with rest initially and now persists
This is characteristic of Distal Ulnar Palsy (DUP), which can commonly occur in long distance cyclists and mountain bikers due to compression of the ulnar nerve in Guyon’s canal as a result of prolonged or excessive pressure.
As in this discussion, it’s important to tease out any provoking factors. Symptoms may arise due to a change in bike, lack of a bike fit, or increase in distance cycled (not questions we’re necessarily used to asking in the ED!). The mainstay of treatment for DUP is modification of activity and of the bike itself. Handlebars can be adjusted by adding shock-absorbing tape or changing their position, a bike fit can be used to ensure proper positioning of the cyclist during their journeys, and distance can be reduced to allow for resolution of symptoms. Importantly, absence of these modifications may lead to atrophy of the intrinsic muscles of the hand.
Other management includes the use of anti-inflammatory medications for localised inflammation to ease compression and steroids if symptoms are ongoing. Surgical management with decompression is rare. If motor function is affected it may take weeks to resolve, however, in the case of prolonged symptoms or other concerns, an OPD EMG can be useful for further evaluation.
RED-S syndrome
Carl astutely queried more about the significant weight loss the patient reports. It is important to tease out the cause of weight loss, whether intentional or unintentional. This man intentionally lost weight to boost his performance, but has noticed increased episodes of sickness, fatigue and a dip in his performance. These signs and his low BMI point to the possibility of Relative Energy Deficiency in Sport Syndrome (RED-S syndrome). As in this case, it is essential not to miss the opportunity to screen for other aetiologies such as malignancy with B-symptoms.
There is more on RED-S Syndrome covered in our last bonus episode to really get up to speed, and don’t forget to consider screening for it in the athletes that cross your path.
Case 3: Road Runner
A 24-year-old female presents to ED complaining of right shin pain for the past few weeks while running. The pain begins after about 1km and worsens progressively as she runs. She has come in for an X-ray.
The history:
Top tip for medical students: The SOCRATES history is a great way to help elicit the aetiology of a patient’s pain.
Medial Tibial Stress Syndrome
This runner has gradually progressive pain along the medial border of her tibia that improves with and is delayed by stretching, lasts after stopping and has some response to NSAIDs. What are some other features of MTSS?
MTSS is an overuse injury characterised by exercise-induced pain typically located along the posterior medial tibial border. It is a precursor to stress fractures and resolves sooner with earlier diagnosis and management. Similar to sprains, loading and resistance exacerbates MTSS symptoms due to traction on tendons and the periosteum. Both also commonly improve with stretching before exercise. Swelling may be present, localised at the muscle insertions of the posterior medial tibial border.
The risk of developing MTSS is higher in long distance runners, members of the military, females, those with a previous history of MTSS, high BMI, and biomechanical factors such as muscle weakness and usage. It is often brought on by an increase in training loads and distances.
MTSS is thought to be due to accumulative microdamage without sufficient recovery time. This may be secondary to excessive traction from the tibialis posterior muscle, or due to overload of the bone itself.
Management of MTSS
Recovery relies on reducing the load and the distance. Patients should be advised to implement non pain provoking activities such as cycling or swimming to maintain fitness without the impact. Notably amateur runners often have a different style of running to professionals, leading to a different weight distribution.
- Shoe orthoses – shift to midfoot running
o Rate of injury remains the same, but lower chance of sustaining MTSS
Pharmacologically, in the acute phase (2-6 weeks) the goal should be minimising pain and providing adequate analgesia with eg. paracetamol, NSAIDs, wrapped ice packs etc. In the subacute phase, runners should aim for a 50% reduction in activity, avoid hills and uneven surfaces and engage in non-impacting exercise.
The role for tailored physiotherapy is often under recognised: balance and proprioceptive exercises have been shown to reduce recurrence. Unfortunately the availability of physiotherapists who specialise in these injuries in the community can be few and far between. The importance of sitting down with the patient and explaining the injury, how it happens and what they can do to aid recovery is therefore all the more relevant.
Alternative therapy: shock wave therapy has been proposed as a treatment for MTSS, however sufficient data is outstanding.
Other differentials to consider:
- Sprain
- Previous injuries: scarring
- Exertional compartment syndrome
- Fracture
- Tendon rupture
- Popliteal artery entrapment
A final note on sports injuries
As discussed in our cases, sometimes patients present requesting imaging without an understanding of whether or not it is required. Safety netting is, as always, important, and so too is letting them know how long it may be normal to experience pain for, or how they should adjust their activities. For avid athletes and sports players, reducing or changing forms of training for a period of time can be a challenge psychologically, particularly if there is a big event happening within that timeframe. Thus, a conversation explaining why it is necessary and the risks of not following advice can help with patient satisfaction and outcomes.
Our infographics
If you’ve gotten this far you’ve read all the notes, so why not check out our infographics which are a perfect summary of the cases. And you can click here to download PDFs of the infographics
And that’s a wrap for this month’s episode. Get involved with the conversation on our socials, we’re on Twitter, Facebook and Instagram. And if you liked the content, and are looking forward to our sports bonus episode in 2 weeks’ time, why not give us a follow and a retweet to spread the word. We’d love to expand our community of learning far and wide.
And in the meantime - may your coffee be strong, and your rounds grand. TCR, out.
REFERENCES
Medial Tibial Stress Syndrome: https://www.ncbi.nlm.nih.gov/books/NBK538479/#:~:text=Medial%20tibial%20stress%20syndrome%20(MTSS)%20is%20a%20frequent%20overuse%20lower,shin%20splints.%E2%80%9D%5B2%5D
BMJ learning on Medial tibial stress syndrome:
https://bjsm.bmj.com/content/45/2/e2.31
Review of long distance running injury frequency:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3497945/
National RED S advice / factsheet:
https://www.sportireland.ie/institute/performance-service/nutrition/red-s
Cyclist ulnar nerve palsy practical summary:
Further info on injury distribution in cycling:
https://bmjopensem.bmj.com/content/6/1/e000840
CDC page on leptospirosis:
https://www.cdc.gov/leptospirosis/symptoms/index.html
General NHS advice for gastroenteritis:
