Sport and Exercise Medicine: The UK trainee perspective – A BJSM blog series

By Robin Chatterjee, Abosede Ajayi, and Fey Probst

Email for correspondence: robin.chatterjee@imperial.nhs.uk

Competing interests: none declared

Introduction

Sports & Exercise Medicine (SEM) is a relatively new and sometimes misunderstood specialty. There is a general preconception that it is solely to do with the medical management of the elite sports person. It is however much more than that and has a vital role to play in the future of a cost-effective, streamlined NHS. There is a paucity of NHS SEM departments in the UK. This case is just one example of how the involvement of SEM physicians can improve the efficacy of patient management.

Case Report

A 44 year old male bus driver presented to the Soft Tissue Injury Management (STIM) Clinic at Charing Cross Hospital. This is a daily clinic, within the Emergency Department, where individuals with acute and chronic musculoskeletal ailments, acute soft tissue injuries or medical problems related to participation in physical activity, exercise or sport are seen by an SEM doctor.

The patient had a 2 year history of worsening acute intermittent left upper limb neuropathic pain with associated multifocal pareses. The pain initially occurred at the shoulder only, but over a period of months had started to radiate down the limb and cause weakness. The pain was not positional in nature but was worse at night and often awoke him when asleep. Each episode was self-limiting with pain ceasing after 2-3 weeks but then recurring again 3-4 months later. The severity of his symptoms had prevented him from working for several months. This consequently induced depression.

The patient had sought the advice of his GP several times and had also at various stages of his illness, had consultations with orthopaedic surgeons, physiotherapists, rheumatologists and a neurologist. He had had many blood tests, x-rays, an MRI scan of his shoulder and MRI brachial plexus, all of which were unremarkable.

When examined in STIM clinic, the patient had pain in the left shoulder and axilla with decreased sensation both in the regimental badge sign area and in the distribution of C6 and C7, together with difficulty in abducting the shoulder (grade 2/5). Ultrasonography of the shoulder was performed during the consultation which demonstrated wasting of the supraspinatus and deltoid muscles.

Nerve conduction studies were subsequently performed which confirmed the diagnosis of Parsonage-Turner Syndrome (PTS). The patient was then referred to an SEM Physician in the private sector for further management.

Overview of Parsonage-Turner Syndrome

PTS (also known as idiopathic brachial plexopathy, brachial neuritis or neuralgic amyotrophy) was first described in the Lancet in 1948¹ and is classically described as a sudden onset, episodic and acute unilateral shoulder girdle pain² that may extend to the upper arm, forearm and the hand³ with night pain and associated neurological weakness, numbness, muscle atrophy and dysesthesia².

It has both an idiopathic and autosomal dominant hereditary form⁴. The current hypothesis is that PTS is secondary to an underlying pre-disposition and a susceptibility to mechanical injury of the brachial plexus; the episodes are then caused by an immune-mediated response to the brachial plexus ^{4, 5}.

PTS affects men more than women⁶ and most patients present between the ages of 30 and 60 years⁷ though it has been reported from 3 months to 75 years⁸. It has an overall reported incidence of 1.64 cases per 100,000 people⁹.

Once preliminary tests such as MRI scan have ruled out alternate pathologies that may be causing the symptoms, electromyography (EMG) and nerve conduction studies (NCS) are the investigations of choice that can positively support the diagnosis of PTS^{10, 11}.

Treatment is composed of pain management, physical therapy and rehabilitation.

PTS has a good prognosis with 80% of patients functionally recovering within 2 years and 90% recovering within 3 years¹². The rate of recurrence in the idiopathic form is 5-26% and 75% in the inherited form¹³. 

Conclusion

In theory the delivery of services and teaching of sport and exercise medicine has been a key concept of the medical profession in the UK since 1912. In practice, only since the formation of the Faculty of Sport & Exercise Medicine (FSEM) in 2006 has a formal SEM training programme been established and NHS SEM departments encouraged^{14, 15}. In light of the specialty being in its infancy, there remains a dearth of SEM clinics available in the public health system. With an ageing, progressively overweight and ever-increasing population, chronic non-operative musculoskeletal morbidity is becoming more and more prevalent. SEM can and should become an integral cog in the wheel of health service delivery in the modern British population were more departments and clinics to become available. The case discussed in this report is one of many examples where early consultation with an SEM specialist can lead to a ‘one-stop-shop’ service where the patient is reviewed in a holistic manner, a diagnosis is reached in a shorter time frame and where unwarranted investigations are avoided. The unique nature of SEM training allows the specialist to have an insight into orthopaedics and rheumatology as well as emergency medicine, public health and exercise physiology too. The end result of this is a two-fold effect of improved efficiency of service delivered to the patient and also reduction of cost within the NHS. The former is achieved, as the SEM physician is skilled in diagnostic techniques such as ultrasonography, interventional procedures such as nerve root blocks and long-term management in the form of exercise prescription and psychological therapies. The NHS can benefit financially as an SEM physician can provide expert triage of both GP and A&E musculoskeletal referrals and thus reduce inappropriate referral to surgical specialties and instead utilise alternate services such as physiotherapy or podiatry.

Although PTS is a rare disorder, there are many common ailments such as atraumatic chronic low back pain, plantar fasciitis, chronic groin pain and obesity, where early consultation with an SEM physician can result in improved patient management (by achieving an early diagnosis and formulation of a definitive management plan) and therefore a reduction in subsequent visits to other healthcare professionals. Ultimately this will result in efficient healthcare management of the individual as well as being cost effective for the NHS as a whole.

References

1. Parsonage MJ, Turner JWA. The Shoulder Girdle Syndrome. Lancet. 1948 Jun 26; 1 (6513): 973-978
2. Feinberg JH, Radecki J. Parsonage-Turner syndrome. HSS J. 2010 Sep; 6(2): 199-205
3. Crooks RJ, Jones DA, Fiddian AP. Zoster-associated chronic pain: an overview of clinical trials associated with acyclovir. Scand J Infect Dis Suppl. 1991; 80: 62-68
4. van Alfen N, van Engelen BGM, Hughes RAC. Treatment for idiopathic and hereditary neuralgic amyotrophy (brachial neuritis). Cochrane Database Syst Rev. 2009 Jul 8; (3): CD006976
5. van Alfen N. clinical and pathophysiological concepts of neuralgic amyotrophy. Nat Rev Neurol. 2011 May 10; 7(6): 315-22
6. Aymond JK, Goldner JL, Hardaker WT. Neuralgic Amyotrophy. Orthop Rev. 1989 dec; 18(12): 1275-9
7. Darby MJ, Wass AR, Fodden DI. Neuralgic amyotrophy presenting to an accident and emergency department. J Accid Emerg Med. 1997 Jan; 14(1): 41-3
8. Cumming WJK, Thrush DC, Kenwood DH. Bilateral neuralgic amyotrophy complicating Weil’s disease. Postgrad Med J. 1978 Oct; 54 (636): 680-1
9. Beghi E, Kurland LT, Mulder DW, Nicolosi A. Brachial plexus neuropathy in the population of Rochester, Minnesota, 1970-1981. Ann Neurol. 1985 Sep; 18 (3): 320-323
10. Suarez GA. Immune brachial plexus neuropathy. In: Dyck PJ, Thomas PK, (eds). Peripheral neuropathy. Elsevier Saunders, Philadelphia. 2299-2308
11. van Elfen N. The neuralgic amyotrophy consultation. J Neurol. 2007 Jun; 254 (6): 695- 704
12. Conway RR. Neuralgic amyotrophy: uncommon but not rare. Mo Med. 2008 Mar-Apr; 105 (2): 168-9
13. van Alfen N, van Engelen BG. The clinical spectrum of neuralgic amyotrophy in 246 cases. Brain. 2006 Feb; 129 (Pt. 2): 438-50
14. McLatchie GR. Sport and exercise medicine- the state of play. Scott Med J. 2010; 55(2): 3-4
15. Chatterjee R. A lasting legacy: clinical commissioning groups and sport medicine. Br J Gen Pract. 2014 Mar; 64(620): 141

*******************************

Robin Chatterjee is a Specialist Registrar in Sports & Exercise Medicine at Charing Cross & Hammersmith Hospitals and also a General Practitioner with a Special Interest in Sports & Exercise Medicine. With a background in anaesthetics he has practised in an eclectic range of fields including Altitude & Hyperbaric medicine, Intensive Care in the Australian Outback, being a trauma physician in Thailand during the 2008 uprising, as well elite sporting events such as the Virgin London Marathon and Dextro Energy ITU Triathlon World Championship Finals.

Dr Abosede Ajayi, known as GB, is an Emergency Medicine Consultant at Charing Cross Hospital, London with a passion for sport and in particular rugby. She is an experienced Sports Physician having worked in international sport for over a decade with a wide array of sports & teams including Chelsea FC Academy, London Harlequins and latterly as Chief Medical Officer to British Diving & Great Britain Wheelchair Rugby. When not next to a rugby pitch or diving pool, in what remains of her spare time, she enjoys listening to, writing & singing gospel music.

Dr Probst trained at St. Mary’s Hospital in Paddington. She undertook rotations in Surgery, Medicine and Emergency Medicine prior to becoming an Emergency Department consultant. She is a BASICS doctor and has been a doctor at several prehospital and sporting events, including Tough Mudder, the London Marathon and triathlons both mass participation and elite. She is best known for a MacGyver approach to life, carrying with her anything which might be needed for any conceivable opportunity.

Dr Farrah Jawad coordinates the BJSM Trainee Perspective blog.