Sport and Exercise Medicine
Canadian Academy of Sport and Exercise Medicine Last updated: September 2023
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Osgood Schlatter disease (OSD) is a clinical diagnosis, based on an appropriate history and typical physical findings. Knee radiographs do not need to be performed if there is no acute concern (such as trauma, suspicion of an avulsion fracture or red flag symptoms such as night pain, joint swelling, constitutional symptoms, etc) and patients are responding to treatment.
Sources:
Circi E. et al. Treatment of Osgood-Schlatter Disease: review of the literature. Musculoskelet Surg 2017;101:195-200. PMID: 28593576.
Gregory JR. Osgood-Schlatter Disease. Medscape.
Joshi A. Osgood-Schlatter Disease imaging. Medscape.
Purushottam A. et al. Osgood Schlatter syndrome. Curr Opin Pediatr 2007;19:44-50. PMID: 17224661.
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Bony injury is more common in children and should therefore be ruled out when assessing injuries in the pediatric patient. Conventional radiography is the primary and usually only imaging modality necessary for evaluating shoulder and knee injuries. Ultrasound should not be ordered as part of the initial diagnostic workup; however, if patients do not respond to conservative management, additional imaging may be necessary.
Sources:
Emery K. Imaging of Sports Injuries of the Upper Extremity in Children. Clin Sports Med 2006;25:543–568. PMID: 16798142.
Gomez J. Upper extremity injuries in youth sports. Pediatr Clin N Am 2002;49:593– 626. PMID: 12119867.
Jacobson JA et al. Ultrasound of the Knee: Common Pathology Excluding Extensor Mechanism. Semin Musculoskelet Radiol 2017;21:102–112. PMID: 28355674.
Kijowski R and De Smet AJ. The Role of Ultrasound in the Evaluation of Sports Medicine Injuries of the Upper Extremity. Clin Sports Med 2006;25:569–590. PMID: 16798143.
Naraghi AM and White LM. Imaging of Athletic Injuries of Knee Ligaments and Menisci:Sports Imaging Series. Radiology 2016;281(1):23-40. PMID: 27643766.
Wolf M. Knee Pain in Children: Part I: Evaluation. PIR 2016;37(1):18-24. PMID: 26729778.
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Scoliosis radiographic series consisting of full spine standing radiographs are not indicated in the evaluation of back pain unless there are clinical signs of scoliosis (asymmetry on Adams forward bend test, asymmetry of the shoulders, etc). When clinically indicated, radiographs are a good initial diagnostic tool to assess back pain but should be limited to the area of interest to limit radiation exposure.
Sources:
American College of Radiology. ACR appropriateness criteria® low back pain [Internet]. 2021 [cited 2021 October 7].
Bhatia NN, Chow G, Timon SJ, Watts HG. Diagnostic modalities for the evaluation of pediatric back pain: a prospective study. J Pediatr Orthop 2008;28(2):230–233. PMID: 18388720.
Booth TN, Iyer RS, Falcone Jr RA, Hayes LL, Jones JY, Kadom N, Kulkarni AV, Myseros JS, Partap S, Reitman C, Robertson RL. ACR Appropriateness Criteria® Back Pain—Child. Journal of the American College of Radiology. 2017 May 1;14(5):S13-24. PMID: 28473069.
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Guidelines from the American College of Radiology (ACR) and the Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) recommend full spine standing posterior-anterior (PA) and lateral radiography on initial examination of scoliosis and using lower-dose radiography techniques when available. Thoracic spine radiographs are not sufficient to evaluate scoliosis as they may not allow for adequate visualization of the curves, especially potential lumbar components. They also do not allow for assessment of the Risser index, a measure of the degree of iliac apophysis ossification and a marker for both skeletal maturity and potential curve progression.
Sources:
Booth TN, Iyer RS, Falcone Jr RA, Hayes LL, Jones JY, Kadom N, Kulkarni AV, Myseros JS, Partap S, Reitme suan C, Robertson RL. ACR Appropriateness Criteria® Back Pain—Child. Journal of the American College of Radiology. 2017 May 1;14(5):S13-24. PMID: 28473069.
Jones JY, Saigal G, Palasis S, Booth TN, Hayes LL, Iyer RS, Kadom N, Kulkarni AV, Milla SS, Myseros JS, Reitman C. ACR appropriateness criteria® scoliosis-child. Journal of the American College of Radiology. 2019 May 1;16(5):S244-51. PMID: 31054751.
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Due to their efficacy, low cost, and low radiation exposure, 2-view plain films are the best initial study. Oblique radiographs detect less than 30% of spondylolysis lesions and pose increased radiation exposure with little to no increased benefit. Advanced imaging (MRI, bone scan +SPECT) may detect stress injury not seen on radiographs.
Sources:Cheung KK, Dhawan RT, Wilson LF, Peirce NS, Rajeswaran G. Pars interarticularis injury in elite athletes – The role of imaging in diagnosis and management. Eur J Radiol. 2018;108:28-42. PMID: 30396669.
Ledonio CG, Burton DC, Crawford III CH, Bess RS, Buchowski JM, Hu SS, Lonner BS, Polly Jr DW, Smith JS, Sanders JO. Current evidence regarding diagnostic imaging methods for pediatric lumbar spondylolysis: a report from the scoliosis research society evidence-based medicine committee. Spine deformity. 2017 Mar 1;5(2):97-101. PMID: 28259272.
Miller R, Beck NA, Sampson NR, et al. Imaging modalities for low back pain in children: a review of spondyloysis and undiagnosed back pain. J Pediatr Orthop 2013; 33:282–288. PMID: 23482264.
Tofte JN, CarlLee TL, Holte AJ, Sitton SE, Weinstein SL. Imaging pediatric spondylolysis: a systematic review. Spine. 2017 May 15;42(10):777-82. PMID: 27669047.
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A significant number of children undergo CT scans for minor head injuries, which are often concussions, exposing children to the potentially harmful effects of ionizing radiation and imposing undue costs to the healthcare system. A number of clinical decision rules for use of CT for minor head injury in children, including PECARN, CATCH and CHALICE rules, have been developed in the last two decades and have shown that children with low risk for clinically important structural brain injury, as in the setting of concussion (no focal neurological deficits, no altered mental state, etc), do not require CT imaging.
Sources:
Babl FE et al. Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study. Lancet 2017;389:2393-2402. PMID: 28410792.
Dunning J et al. Derivation of the children’s head injury algorithm for the prediction of important clinical events decision rule for head injury in children. Arch Dis Child. 2006; 91(11):885-91. PMID: 17056862.
Kuppermann N et al. Identification of children at very low risk of clinically important brain injuries after head trauma: a prospective cohort study. Lancet 2009;374:1160-1170. PMID: 19758692.
Osmond M et al. Validation and refinement of a clinical decision rule for the use of computed tomography in children with minor head injury in the emergency department. CMAJ 2018 July 9;190:E816-22. PMID: 29986857.
Purcell L, CPS, Healthy Active Living and Sports Medicine Committee. Sport-related concussion: evaluation and management. Paediatr Child Health 2014;19(3): 153–158. PMID: 24665227.
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Complex regional pain syndrome (CRPS) is a chronic severe pain condition that involves peripheral, central and autonomic nervous system and immune system mechanisms. Immobilization of the painful area can lead to prolonged symptoms and poor outcomes and should be avoided unless required for underlying pathology such as fracture management.
Sources:
Canadian surveillance study of complex regional pain syndrome in children. Baerg KL, Tupper SM, Chu LM, Cooke N, Dick BD, Doré-Bergeron MJ, Findlay S, Ingelmo PM, Lamontagne C, Mesaroli G, Oberlander T, Poolacherla R, Spencer AO, Stinson J, Finley GA. PAIN 2021 Sep 13. PMID: 34799536.
Sherry, DD, Wallace, CA, Kelley, C. Short- and long-term outcomes of children with complex regional pain syndrome type I treated with exercise therapy. Clin J Pain 1999; 15(3): 218–223. PMID: 10524475.
Weissmann R, Uziel Y. Pediatric complex regional pain syndrome: a review. Pediatric Rheumatology. 2016 Dec;14(1):1-0. PMID: 27130211.
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Most if not all buckle fractures heal without complications. Follow up radiographs are not indicated if symptoms have resolved, as this will expose the child to unnecessary radiation.
Sources:
Ben-Yakov M, Boutis K. Five things to know about buckle fractures of the distal radius in children. CMAJ. 2016 April 19; 188 (7): 527. PMID: 26976961.
Handoll_HHG, Elliott_J, Iheozor-Ejiofor_Z, Hunter_J, Karantana_A. Interventions for treating wrist fractures in children. Cochrane Database of Systematic Reviews 2018, Issue 12. PMID: 30566764.
Koelink E, Schuh S, Howard A, et al. Primary Care. Physician Follow-up of Distal Radius Buckle Fractures. Pediatrics. 2016;137(1):e20152262. PMID: 26729537.
Riera-Alvarez L, Pons-Villanueva j. Do wrist buckle fractures in children need follow-up? Buckle fractures’ follow up. J Pediatr Orthop B. 2019; 28: 553-554. PMID: 31305367.
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The Canadian Academy of Sport and Exercise Medicine (CASEM) Board approved the development of pediatric-specific sport and exercise medicine (SEM) Choosing Wisely Canada’s recommendations. A small working group was created to review existing Choosing Wisely Canada recommendations. The working group then created a list of suggested pediatric-specific SEM recommendations based on existing research, experience and common practice patterns. This list was then sent to the Pediatric Interest Group of CASEM, as well as a pediatric orthopedic surgeon and a pediatric MSK radiologist at McMaster University, to seek feedback on each suggested recommendation. Following revisions based on the feedback, a national survey was conducted with CASEM’s membership to solicit members’ feedback for each recommendation. Further revisions were made by the working group and the list was then sent to CASEM’s publication committee for review and feedback. Final edits were made and approved for submission to Choosing Wisely Canada by the CASEM Board.
Canadian Academy of Sport and Exercise Medicine Last updated: September 2023
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Degenerate meniscal tears and osteoarthritis (OA) are extremely common in the general population. Early degenerative changes in the meniscus can be found in many subjects under the age of 30. By 50 to 60 years of age, full degenerative meniscal tears are commonly found in 33-50% of subjects. Unless associated with the presence of osteoarthritis (OA), these degenerative meniscal tears are most often asymptomatic. Magnetic resonance imaging (MRI) is not recommended for degenerative meniscal tears unless there are mechanical symptoms (e.g., locking) or lack of improvement with conservative treatment (exercise/therapy, weight loss, bracing, topical or oral analgesia, intra-articular injections). MRI is not recommended for the diagnosis or management of OA. Weight-bearing X-rays should be ordered instead.
Sources:
Arthritis Alliance of Canada. The Impact of Arthritis in Canada: Today and Over the Next 30 Years [Internet]. 2011 [cited 2017 May 5].
Buchbinder R, et al. Management of degenerative meniscal tears and the role of surgery. BMJ. 2015;350:h2212. PMID: 26044448.
Englund M. The role of the meniscus in osteoarthritis genesis. Rheum Dis Clin North Am. 2008;34:573-9. PMID: 18687273.
Englund M. Meniscal tear — a common finding with often troublesome consequences. J Rheumatol. 2009;36:1362-4. PMID: 19567632.
Englund M, et al. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med. 2008;359:1108-15. PMID: 18784100.
Strobel MJ. Manual of Arthroscopic Surgery. Springer: Verlag Berlin Heidelberg; 2002;1:99-200.
US Department of Veteran Affairs. VA/DoD Clinical Practice Guidelines: The Non-Surgical Management of Hip & Knee Osteoarthritis (OA) [Internet]. 2014 [cited 2017 May 5].
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Tendinopathy is a broad term encompassing painful conditions occurring in and around tendons in response to overuse. Although acute inflammatory tendinopathies (i.e., tendinitis) exist, most patients seen in primary care will have chronic symptoms (tendinosis). Multimodality options (e.g., relative rest, activity modifications, physical or athletic therapy, etc.) should be considered as the first line treatment of tendinopathies. Opiates should not be used in the initial phase of treatment.
Sources:
Andres BM, et al. Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clin Orthop Relat Res. 2008;466:1539-54. PMID: 18446422.
Fanelli G, et al. Opioids for chronic non-cancer pain: a critical view from the other side of the pond. Minerva Anestesiol. 2016;82:97-102. PMID: 26173558.
Khan KM, et al. Histopathology of common tendinopathies. Update and implications for clinical management. Sports Med. 1999;27:393-408. PMID: 10418074.
Wilson JJ, et al. Common overuse tendon problems: A review and recommendations for treatment. Am Fam Physician. 2005;72:811-8. PMID: 16156339.
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Pes planus is common in children. Although it rarely leads to disability, it is still a major concern for parents and is a common cause of clinic visits for pediatric foot problems. Most pediatric pes planus cases are characterized by a normal arch during non-weight bearing, and a flattening of the arch on standing. They are often painless, non-problematic, and resolve by adolescence. The current evidence suggests that it is safe and appropriate to simply observe an asymptomatic child with flexible pes planus.
Sources:
Carr JB 2nd, et al. Pediatric Pes Planus: A State-of-the-Art Review. Pediatrics. 2016 Mar;137(3):e20151230. PMID: 26908688.
Halabchi F, et al. Pediatric flexible flatfoot; clinical aspects and algorithmic approach. Iran J Pediatr. 2013;23:247-60. PMID: 23795246.
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Initial management of rotator cuff tendinopathy includes relative rest, modification of painful activities, and an exercise program guided by a physical therapist or athletic therapist to regain motion and strength. The addition of subacromial cortisone/local anesthetic injections may be helpful. Should conservative management fail to relieve pain and restore function of the shoulder, consider plain radiographs to rule out bony or joint pathology, and ultrasound to assess for rotator cuff and bursal pathology. MRI or MRA (MR arthrogram) should be considered if symptoms don’t resolve with conservative therapy and there is a concern of labral pathology.
Sources:
Anderson MW, et al. Imaging evaluation of the rotator cuff. Clin Sports Med. 2012;31:605-31. PMID: 23040549.
Harrison AK, et al. Subacromial impingement syndrome. J Am Acad Orthop Surg. 2011;19:701-8. PMID: 22052646.
Lewis J, et al. Rotator Cuff Tendinopathy: Navigating the Diagnosis-Management Conundrum. J Orthop Sports Phys Ther. 2015;45:923-37. PMID: 26390274.
Roy JS, et al. Diagnostic accuracy of ultrasonography, MRI and MR arthrography in the characterisation of rotator cuff disorders: a systematic review and meta-analysis. Br J Sports Med. 2015;49:1316-28. PMID: 25677796.
Thomopoulos S, et al. Mechanisms of tendon injury and repair. J Orthop Res. 2015;33:832-9. PMID: 25641114.
Yablon CM, et al. Rotator cuff and subacromial pathology. Semin Musculoskelet Radiol. 2015;19:231-42. PMID: 26021584.
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Ankle sprains are among the most common injuries seen in the ER or physician clinics. Ankle sprains cause a high incidence of absenteeism in professional and physical activities with important economic consequences. There is good evidence to show that functional bracing of the ankle instead of rigid immobilization is associated with improved and earlier functional improvement and an overall shorter recovery period. For ankle inversion sprains with no associated bony or syndesmotic injury, early mobilization using a functional ankle brace and physiotherapy/athletic therapy should be considered instead of rigid immobilization.
Sources:
Cooke MW, et al. Treatment of severe ankle sprain: a pragmatic randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of three types of mechanical ankle support with tubular bandage. The CAST trial. Health Technol Assess. 2009;13(13):1-65. PMID: 19232157.
Mizel MS, et al. Evaluation and treatment of chronic ankle pain. Instr Course Lect. 2004; 53:311-21. PMID: 15116624.
Prado MP, et al. A comparative, prospective, and randomized study of two conservative treatment protocols for first-episode lateral ankle ligament injuries. Foot Ankle Int. 2014;35:201-6. PMID: 24419825.
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The Canadian Academy of Sport and Exercise Medicine (CASEM) Board approved the development of Choosing Wisely Canada’s recommendations. A small working group was created to review existing Choosing Wisely Canada recommendations. The CASEM Board then created a list of suggested recommendations based on existing research, experience and common practice patterns. A national survey was conducted with CASEM’s membership, soliciting members’ feedback for each recommendation. The five recommendations with near unanimous support were selected to be included in CASEM’s Choosing Wisely Canada’s Top 5 List. Each recommendation was further developed by the small working group, and submitted to CASEM’s publication’s committee for review and feedback. Final edits were made and approved for submission to Choosing Wisely Canada by the CASEM Board.