Heat Illness in Athletes

As summer approaches, athletes, coaches and other individuals will need to be aware of heat-related illnesses. Heat illnesses include a spectrum of conditions ranging from heat syncope, heat cramps and heat exhaustion to the more severe heat stroke.

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Heat Syncope (fainting) is a form of orthostatic hypotension that is related to dehydration. It occurs due to inadequate cardiac output and hypotension. It also occurs with standing quickly after sitting or lying down for prolonged durations in the heat. Symptoms include fainting, dizziness and light-headedness. Treatment includes oral rehydration (water, juice or sports drinks) and placing the patient flat on the ground in a cool area with slight elevation of the legs to push the blood back to the vital organs such as the brain.

Heat Cramps are painful muscle cramps that occur due to decreased sodium heat2.pngconcentration in the blood. The patient’s core temperature is usually not elevated. Sodium may decrease when salts are lost in sweat or with excessive water intake that does not include electrolytes leading to a situation called dilutional hyponatremia. Symptoms include painful muscle cramps occurring commonly in the abdominal muscles, arms, legs and thighs. Treatment includes rest, cooling and IV fluids or oral rehydration with fluids rich in electrolytes (sports drinks and juices) to replenish the sodium stores. Prevention could be achieved by consumption of fluids high in electrolytes before strenuous activities.

heat3Heat Exhaustion is the most common heat illness. The body temperature becomes elevated but is less than 40°C. The core body temperature is best measured rectally. The signs and symptoms of heat exhaustion include profuse sweating, core body temperature lower than 40°C, weakness and fatigue, cramping, headaches, nausea and vomiting,  fainting, hypotension, increased heart rate, and fast shallow breathing. Treatment includes rest, IV fluids or oral rehydration and rapid cooling by whole-body immersion in an ice bath.

Heat Stroke is the most severe form of heat illness. It is a medical emergency that needs immediate attention. The patient should be transported to the hospital as soon as possible. Heat strokes occur due to failure of the body’s normal thermoregulatory mechanism. If treatment is not started promptly, end-organ failure and ultimately death may occur. Heat strokes have a high mortality rate and require quick reduction of the patient’s temperature. The three characteristic features of this condition are a lack of sweating, core body temperature above 40°C (best measured rectally) and an altered mental status. Additional signs and symptoms include hot, dry skin, disorientation, confusion and hallucinations, headache and slurred speech. This is a serious medical emergency that requires rapid core body temperature reduction. The patient should have close monitoring of airway, breathing and circulation. The physician should implement basic life support and ACLS protocols. Rapid cooling by whole-body immersion in an ice bath will be utilized as well as IV fluids.

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What is Brachial Neuritis?

Brachial Neuritis is a condition of severe shoulder pain that usually radiates dowbrachial1n the arm and up to the neck and scapula. It can also be referred to as neuralgic amyotrophy (NA) and/or parsonage-turner syndrome. The pain is sudden, severe and may last for a few weeks. This pain may disturb sleep! It usually occurs on its own without a history of trauma. The condition occurs more in males and it may occur at any age.

The position of comfort is the shoulder adducted with the elbow flexed. Neck movement and Valsalva’s maneuver do not increase the pain. Pain is increased by movement of the arm. Although the pain is severe and sudden, lasting at least a few weeks, the condition is usually under diagnosed or not diagnosed at all.

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Weakness may be absent in the acute phase, however as the pain resolves, weakness of certain muscles will remain. The degree of weakness correlates with the severity of the initial pain.

brachial3The muscles that are commonly involved are the supraspinatus and the infraspinatus muscles. The suprascapular nerve is the most commonly involved followed by the deltoid, which is the abductor of the s shoulder innervated by the axillary nerve.

The condition may occur bilaterally and may occur subclinically (only seen on an EMG). Muscle weakness may continue for a significant period of time. Sensory changes may be variable. If there is no sensory loss, this is a classic finding that confirms the diagnosis. There is a decreased sensation in a lot of cases. The lateral antebrachial cutaneous nerve is usually involved.

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Motor changes predominantly occur over sensory changes and can involve the brachial plexus from C5-T1 with a variable degree of weakness. It can affect more than one nerve branch with certain patterns of involvement can be seen on the MRI.

It is a benign, self-limiting problem with 90% of patients returning to near normal condition in about 3 years. Only about 1/3 of the patients will recover at about 1 year. The etiology of brachial plexus neuritis is unknown.

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Hyperintense muscles involved in the sagittal plane (supraspinatus, infraspinatus, and deltoid). In advanced cases, the muscles will either be atrophied or have fatty infiltration.

EMG and Nerve studies are helpful for the diagnosis and the prognosis. In the first 4 weeks, there will be acute denervation in the roots and the peripheral nerves. EMG may be abnormal for up to 7 years after the diagnosis.

Rule out other conditions such as radiculopathy from a herniated disc. This can bebrachial6 excluded from imaging of the cervical spine. Other conditions that may be considered differential diagnoses are adhesive capsulitis and lyme disease. There are two particular conditions that are very interesting with acute brachial neuritis. The first is bilateral interosseous nerve palsy, which is caused by viral brachial neuritis. The patient has the inability to do the Ok sign. It is motor loss that follows intense shoulder pain and usually the condition resolves with time.

The second condition is winging of the scapula. The serratus anterior muscle involvement may cause dull aches and pain. Acute, sudden severe pain consider with acute brachial neuritis that involves the C7 nerve root. C7 nerve root gives the long thoracic nerve, which innervates the serratus anterior muscle. If the patient has severe shoulder pain and winging of the scapular rule out brachial neuritis!

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The treatment includes rest, observation and steroid injections. Avoid using a sling, a sling will cause flexion and internal rotation contracture of the shoulder. The sling may also cause a stiff elbow.

Baker’s Cyst

 

A baker’s cyst is a benign swelling behind the knee. A baker’s cyst is also known as popliteal cyst which lies posterior to the medial femoral epicondyle. The cyst is connected to the knee joint through a valvular opening. Knee effusion from intra-articular pathology allows the fluid to go through the valve to the cyst in one direction. The cyst is located between the semi membranous and medial gastrocnemius muscles. 

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The patient usually has swelling behind the knee, with pain, fullness and tenderness. A baker’s cyst is easier to see with the knee fully extended. Diagnosis is confirmed by MRI that will show the associated intra-articular pathology. Ultrasound is helpful as well.  These tests are important especially if the cyst is found to be outside of its typical position.

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The two most common causes of baker’s cyst are knee arthritis and meniscal tear. Treatment of painful large cysts may include ice, compressions wrap, corticosteroid medication, strengthening exercises and aspiration of the cyst. Recurrence of baker’s cyst is common if the intra-articular pathology continues. The best treatment is arthroscopy and debridement of the intra-articular pathology.

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The cyst may burst causing calf pain and swelling. Rule out deep venous thrombosis or thrombophlebitis.

Popliteal cysts in children is a common soft tissue mass at the back of the knee. It occurs more in boys and it is asymptomatic. It is not a tumor. It is treated by observation, no surgery needed. It is not associated with a meniscal tear.

Gait

Gait is the pattern of how a person walks. We will be discussing different gait abnormalities.

Antalgic gait

Antalgic gait is a painful gait. A patient with antalgic gait does not want to spend time on the one leg due to pain. A patient wants to get their weight off the affected extremity. When pain is increased by walking, it leads to an antalgic gait (Figure 1).

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An antalgic gait can be caused by multiple factors due to pain in any part of the lower extremity. It is usually caused from hip or knee pathology or from severe disc radiation symptoms (Figure 2).

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The pain can be helped by using a cane on the opposite side of the painful extremity.

Trendelenburg gait

Trendelenburg gait is an abnormal gait that is usually found in people with weak abductor muscle of the hip which is supplied by the superior gluteal nerve. The patient cannot abduct the affected hip due weakness of the abductor muscles on the affected side. If the patient has weakness on one side of the pelvis and when the patient stands on that side, the pelvis on the contralateral side will drop. This is called Trendelenburg sign. A positive Trendelenburg sign occurs when there is dysfunction of the abductor muscles and the body is unable to maintain the center of gravity on the side of the stance leg (Figures 3, 4). The patient will show an excessive lateral lean to keep the center of the gravity over the stance leg.

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Weakness can also occur in patients with L5 radiculopathy or avulsion of the abductor muscle tendon (Figure 5) which occurs with increasing frequency after hip replacement surgery.

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The superior gluteal nerve injury is a major factyor in this gait. With bilateral weakness of the abductor muscles, the patient will have dropping of the pelvis on both sides during walking which leads to a waddling motion. This gait is seen in patients with myopathies.

Slap gait

Slap gait occurs due to weakness of the foot and ankle dorsiflexors which allows the foot slap down on the floor with each step. Slap gait is a heel gait abnormality that can be diagnosed by hearing the patient walk with a normal walking gait, the heel strikes the ground first followed by controlled relaxation of the foot and ankle dorsiflexors in order to allow the forefoot to come in contact with the ground

Steppage gait

Foot drop gait or steppage gait is due to total paralysis of the ankle and foot dorsiflexors (Figure 6). it is sometimes called neuropathic gait. A common symptom of foot drop is a high steppage gait that is often characterized by raising the thigh up in an exaggerated fashion while walking. The patient must externally rotate the leg or flex the hip or knee to raise the foot high enough to avoid dragging the toes along the ground. If the patient has foot drop then they have to have a high steppage gait or else they will trip on the foot and fall forward.

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Conditions causing foot drop include L4-L5 disc herniation, a herniated disc compressing the L5 nerve root may cause foot drop, lumbosacral plexus injury due to pelvic fracture (Figure 7), hip dislocation leading to injury of the common peroneal nerve (Figure 8) and injury to the knee as knee dislocation (Figure 9).

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Wide based gait

A wide based gait occurs due to myelopathy and neurological disorders. This gait disturbance is described as clumsy, staggering movements. It can be associated with cervical or thoracic spine pathology. Patient example of myelopathy with significant cervical spine disc compression of the spinal cord can be seen in Figure 10.

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Patient will have a slow, wide, broad based ataxic gait. The patient will have a wide stance as they try to maintain balance. There will be unsteadiness of the trunk with excessive shift in the center of the gravity.

Gluteus maximus gait

When the gluteus maximus muscle (Figure 11) is week, the trunk lurches backwards (extension of the trunk). It occurs at heel strike on the weakened side to interrupt the forward motion of the trunk. This compensates for weakness of hip extension. The function of the gluteus maximus muscle is external rotation and extension of the hip joint.

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