The Emergency Room Athlete
Frank A. Paul
Frequently, emergency medical patients and athletes have a musculoskeletal component to their presenting complaint, or it may be their primary concern or a finding during the physical examination. The treatment should conform to the standard of care. This care plan should include the use of manual medicine, which has been a part of the therapeutic health care armamentarium for over 2,000 years (1).
One of the goals in treatment of acute musculoskeletal injuries is to decrease edema in the injured area. Therapies that decrease motion restrictions and optimize physiologic range of motion help decrease swelling and improve recovery. Lymphatic drainage and venous return are facilitated through three mechanisms: (a) gravitational forces, (b) pressure changes generated through respiration within the thoraco-abdominal-pelvic cylinder, and (c) musculoskeletal activity generating a pumping mechanism.
Application of manual medicine provides the patient with the potential for an improved structure—function relationship, which should facilitate lymphatic drainage and venous return. Table 43.1 contains a list of contraindications to the use of manipulation in the emergency department patient.
INITIAL EMERGENCY ROOM INTERVENTION
A clear, concise protocol for the diagnosis of sports injuries and concomitant musculoskeletal injuries must be established. First, the emergency room (ER) physician needs to rule out life-threatening and neurovascular emergencies quickly. A history of the injury and a relevant physical examination follow. The often-used Ottawa knee and ankle rules were devised to decrease the unnecessary use of standard radiographs in these common areas of injury.
Appendicular bone and joint computed tomography (CT) and magnetic resonance imaging (MRI) studies are typically outpatient procedures, whereas axial spine fractures may be detected only on CT and should be a part of the athlete’s emergency evaluation if clinical suspicion warrants the study.
The reduction of closed dislocations and minor fracture deformities is typically delayed until the prereduction condition is established and documented with standard radiographs. Exceptions include the presence of any neurovascular compromise distal to the derangement or significant tenting of the overlying tissue. In these cases, prompt reduction to a more native anatomic position should be performed.
Salter-Harris type I fractures are difficult to rule out using standard radiographs in the setting of pain due to injury of a nonfused growth zone. Therefore, regardless of the findings using standard radiographs, potential injuries to epiphyseal plates should be treated as a fracture until proved otherwise with immobilization and serial examinations during follow-up evaluations. Ligamentous injury is common in the athletic patient. Passive range of motion and ligamentous testing should be deferred until ruling out significant structural damage or bony instability. MRI is the study of choice to rule out ligamentous instabilities of the axial spine. The ER physician should have a low threshold for ordering urgent studies of the axial spine.
TABLE 43.1. MANUAL MEDICINE IMPLEMENTATION IN THE EMERGENCY DEPARTMENT | ||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
Significant concomitant musculoskeletal injuries can be distracting, effectively masking visceral and spinal trauma. A history of the injury and a relevant physical examination to rule out concurrent injuries must be thorough and comprehensive.
Standard Treatment Approach
The key to treating the athlete in the emergency room is ruling out high morbidity conditions quickly. The sooner a diagnosis is made, the sooner proper treatment can begin. For the competitive athlete, each missed step along the way can delay return to sport by days or sometimes weeks. The average ER patient, by contrast, usually does not have such temporal restrictions.
The typical acute sports injury is initially treated with the PRICE protocol—protection, rest, ice, compression, and elevation. Oral analgesics should be provided when there is no need for immediate surgical intervention. Otherwise, the use of parenteral pain management is indicated. Aftercare instructions should include prompt outpatient reevaluation to ensure the institution of aggressive physical or occupational therapy. This also prevents complications from prolonged splinting and immobilization while enhancing compliance with the treatment plan.
Manual Medicine Approach
The stable ER athlete examination should follow a comprehensive structural approach that includes the components listed in Table 43.2. Decisions about the utility of manual medicine can then be made. Because initial standard radiographs cannot always rule out a fracture, all areas that are potentially fractured should not be manipulated with direct techniques.
Direct techniques should be used only in areas where the absence of fracture is certain and only by the skilled practitioner at this stage of treatment. These areas benefit from balanced membranous tension, indirect myofascial release, and craniosacral techniques. These techniques are usually well tolerated by the patient and reduce muscular spasm and vascular congestion, facilitating venous drainage and lymphatic return.
Direct techniques should be used only in areas where the absence of fracture is certain and only by the skilled practitioner at this stage of treatment. These areas benefit from balanced membranous tension, indirect myofascial release, and craniosacral techniques. These techniques are usually well tolerated by the patient and reduce muscular spasm and vascular congestion, facilitating venous drainage and lymphatic return.
TABLE 43.2. COMPONENTS OF THE STRUCTURAL EXAMINATION | ||||||
|---|---|---|---|---|---|---|
|
LOW BACK PAIN
The ER evaluation should include a complete review of symptoms, history of present illness, preexisting health problems, and an assessment of the patient’s ability to function with these symptoms. Past medical, surgical, family, social history, and current medications all should be obtained. The differential diagnosis of low back pain is enormous, so do not assume the athlete’s complaint is isolated to one body system or that the complaint is associated with age-related degenerative disc disease.
The physical examination is essential for sorting through the potential causes for low back pain. Acute sports injuries should have a mechanism of injury, so attempt to obtain it from the athlete, trainer, parents, ambulance driver, or coach. Abnormal vital signs should not be dismissed as being caused by musculoskeletal pain without considering other system pathologies. Temperature elevation may be as simple as a component of the flu with accompanying myalgias or as a consequence of physical activity. However, it may indicate urinary, peritoneal, retroperitoneal, inflammatory, or spinal infectious processes.
The acute pain response can elevate the heart rate through autonomic mechanisms, but the differential diagnosis for any person with isolated tachycardia, including shock, should be factored into the clinical picture. Elevation of blood pressure can be secondary to pain but may be reflective of renal, aneurysmal, central nervous system, or circulatory origins of back pain. A rise of the diastolic component of blood pressure, causing a narrowed pulse pressure, may also be indicative of shock, as this component of blood pressure measurement rises with moderate volume loss, while the systolic pressure remains unchanged. Sustained tachypnea should not be overlooked as a pain-moderated physiologic response.
The structural examination can begin on arrival to the emergency room. Notice posture, method of arrival, positioning, and movement while in the ER. This can be accomplished with minimal additional time added to the physical examination and obtained almost entirely with the patient in the supine position. Pertinent laboratory and clinical radiologic studies should be performed to confirm the clinical impression. A high level of clinical suspicion for occult neoplastic or inflammatory processes should be maintained, particularly with a history of trauma (2).
The clinician should eliminate the emergent causes from the differential diagnosis before arriving at a musculoskeletal diagnosis or instituting manual medical treatments. Pain relief and muscle relaxation facilitate the movement of interstitial fluids and decrease the stresses on inflamed tissues. Care for significant musculoskeletal back pain should include use of skeletal muscle relaxants, nonsteroidal anti-inflammatory agents (NSAIDs), and narcotic analgesics. Early rest is recommended followed by an increase in level of activity as tolerated. The athlete should be given comprehensive aftercare instructions, with timely follow-up. Documentation should include the physical findings necessitating the intervention, modalities used, subjective treatment toleration, the degree of mobilization achieved with treatment, and the results of a post-treatment neurovascular examination.
Manual Medicine Treatment
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
