SPORTS INJURIES

Indiana Osteopathic Association 32 nd Annual Winter Update December 6,2013 D A V I D C . K O R O N K I E W I C Z , D . O .

I U G O S H E N O R T H O P E D I C S & S P O R T S M E D I C I N E

Sports Injuries-Outline

• • • 

Overview

Types of injuries Prevention Specific injuries

Statistics

   In the United States, about 30 million children and teens participate in some form of organized sports, and about 3.5 million injuries occur each year.

Participation in high school athletics is increasing, with more than 7.3 million high school students participating annually * High school athletes account for an estimated 2 million injuries and 500,000 doctor visits and 30,000 hospitalizations each year.

** *(Source: National Federation of State High School

Associations)

**JS Powell, KD Barber Foss, 1999. Injury patterns in selected high school sports: a review of the 1995 1997 seasons. J Athl Train. 34: 277-84.

Injuries

Most sports and recreational injuries are the results of: sprains (ligamentous injuries), strains (musculotendinous injuries),and contusions. Knee injuries (meniscal & ACL), bursitis, fractures, and dislocations are all commonly seen.

Top 15 Sports/Recreational Injuries*

        Basketball: 512,213 Bicycling: 485,669 Football: 418,260 Soccer: 174,686 Baseball: 155,898 Skateboards: 112,544 Trampolines: 108,029 Softball: 106,884        Swimming/Diving: 82,354 Horseback riding: 73,576 Weightlifting: 65,716 Volleyball: 52,091 Golf: 47,360 Roller skating: 35,003 Wrestling: 33,734 *Treated in ER based on data from the US Consumer Produce Safety Commission on Injuries

Acute vs. Overuse Injuries

 Acute - sudden trauma causing sprains, strains, bruises & fractures  Overuse - series of repeated small injuries resulting in pain

Causes of Overuse Injuries

 Increasing activity too quickly  Running or jumping on hard surfaces  Training vigorously without adequate rest  Poorly functioning equipment  Improper techniques  Working through pain  Lack of stretching/strengthening

When to See the Physician

     Decreased ability to play Inability to play Limp, loss of motion or swelling Visible deformity Severe pain

Injury Classifications

   

Sprains:

injuries to ligaments

Strains:

injuries to muscles, tendons or the junction between the two

Contusions:

common bruises or contusions are the most frequent sports injury.

Fractures & Dislocations:

fractures and dislocations represent two categories of injuries involving either bones or joints of the body

Preventing Sports Injuries

 Know and abide by rules  Wear appropriate protective gear  Know how to use equipment  Never “play through pain”

Preventing Sports Injuries

 Skilled sport specific instruction  Year round conditioning

Preventing Sports Injuries

Make Sure Your Athletes Always Warm Up First!

Preventing Sports Injuries

WARM UP

     Break a sweat Marching Walk in place Jumping jacks Mimic the sport you are about to do

Stretching Stretching:

      Breathe slowly and deeply Relax into the stretch Should not feel pain Avoid bouncing Hold stretch 30 seconds Stretch both sides

Injuries

MOST COMMON Strains & Sprains

THIS NOT THAT

Strain

Strain  Overstretching of a muscle   Caused by overexertion or by lifting Frequent site is the Back

Signs & Symptoms   Localized swelling Cramping    Inflammation Loss of function Pain   General weakness Discoloration

Strains

Prevention   Proper warm-up Stretch   Proper mechanics Proper cool-down/ stretch  Proper nutrition & hydration

Strain

 First aid treatment  Rest the muscle affected while providing support  Cold applications initially to reduce swelling  Warm wet applications applied later because warmth relaxes the muscles  Obtain medical help for severe strains and back injuries that don’t improve

Sprain

Sprain  Injury to the tissues surrounding a joint   Usually occurs when part is forced beyond its normal range of motion Ligaments, tendons and other issues are stretched or torn   Common sites for sprains are the ankles and wrists Signs and symptoms   Swelling, pain and discoloration Impaired motion at times

Sprain

 First aid for sprain 

R

est and limited or no movement of the affected part 

I

ce to reduce swelling and pain 

C

ompression with elastic bandage to control swelling 

E

levation of the affected part  Obtain medical help if swelling is severe or if there is any question of a fracture

    Bruise Sudden traumatic blow to body (severe compression force) Usually injury to blood vessels under skin Speed of healing depends on tissue damage and internal bleeding

Contusion

 Hematoma formation is caused by a pooling of blood and fluid in a tissue

Tendon Injuries

 Tears commonly at muscle belly, musculotendinous junction, or bony attachment  Tendonitis: inflammation of tendon muscle attachments, tendons, or both

Tendonitis

  Signs & Symptoms   Pain & inflammation Worse with movement Treatment  RICE    NSAIDs-Advil, Aleve Ultrasound therapy Rehabilitation  Prevention    Slowly increase intensity & type of exercise Don’t try to do more than ready for Proper warm-up & stretch

Skeletal Injuries

Subluxation  Occurs when bone displaces and partially separates Dislocation  Excessive force that causes the ends of the bone to separate and usually remain apart requiring them to be put back together

Fracture

Fracture is a break or loss of structural continuity in a bone Wrist/Forearm Fractures

Why

are Injuries on the Rise?

• • • • • • Increase youth participation Immature bones and muscles Insufficient rest after an injury Poor training or conditioning Specialization in just one sport Year-round participation

Children & Sports

Youths of same age can differ tremendously in size and physical maturity.

Injuries in Female Athletes

Injuries in Female Athletes

 Common injuries in women/girls include:  Anterior cruciate ligament (ACL) injuries   Patellofemoral pain syndrome Stress fractures

ACL

   Girls Soccer – 1 torn ACL for every 6,500 times a girl competes or practices Boys Football – 1 torn ACL for every 9,800 times a guy competes or practices Girls Basketball – 1 torn ACL for every 11,000 times a girl competes or practices

ACL Injury

    Direct blow to knee Non-contact injury, with foot plant Landing on straight leg Making abrupt stops

ACL

ACL Injuries

 400,000 reconstructions per year in the US  Females 4 times more likely to tear ACL with non-contact injury

ACL

  Women have an increased predisposition to ACL injury Many theories, but no one proven definitive cause

ACL Injuries

 Intrinsic factors:  Joint laxity  Hormones  Limb alignment  Ligament size   Intercondylar notch size  Extrinsic factors:     Conditioning Experience Skill Strength   Muscle recruitment patterns   Landing techniques

ACL

  Female athletes rely more on their quads and calf muscle than their hamstrings Jumping & landing techniques in women are also different

 ACL

MRI

Normal Torn-ACL

ACL- What to do?

Prevention

 Learn how to fall, jump and to cut   Plyometric training  Reduce landing forces and improve strength ratios (quadriceps:hamstrings) Increase hamstring activation

Hip Pain in Runner

    18 year old female runner with 1 month of anterior groin/inguinal pain Pain worse with weight bearing Over past week she has developed night pain What are the possibilities?

Differential Dx.

       Torn adductor muscle Avulsion of adductor or sartorius muscle Pubic ramus fracture Femoral neck fracture Femoral shaft fracture SI joint subluxation Ruptured iliopsoas bursa

Physical Exam

 Swelling noted in groin and high proximal femur  Pain with all attempts at motion, especially internal rotation  Distal pulses 2+  No distal sensory deficits

Do You Need X-rays?

AP Hip X-ray

MRI

Femoral Neck Stress Fracture

    Groin pain in runner or jumper- don’t ignore Female triad at increased risk as well as those with an increase in training and postmenopausal women Need to know which side the stress fracture is on (compression vs tension side) Plain films often negative  Get MRI

Treatment

    If stress fracture by x-ray or further imaging  Compression side  12 weeks to heal +/- NWB  Tension side  Ortho consult/surgery Femoral neck fracture surgery Cross train Proper nutrition and calories

Complications if Missed

    Stress to complete fracture Avascular necrosis Chronic pain End of career

Patellofemoral Pain Syndrome

  Anterior knee pain Probably more than one etiology   Chondromalacia (softening of cartilage) Malalignment of patella

Patellofemoral Pain Syndrome

Patellofemoral Pain Syndrome Clinical Features and Exam:

 Reports of anterior knee pain    Pain with climbing stairs and/or sitting for prolonged periods of time Pressure on the kneecap during bending and straightening of the knee may elicit cracking and popping with discomfort Abnormal kneecap alignment   Genetic Acquired

Patellofemoral Pain Syndrome

  Other causes  Muscle imbalances    Foot type (either flat or high arched feet) Shoes Overuse Treatment includes: decreasing activity, correct alignment issues, physical therapy for strengthening, bracing or taping

Patellar Dislocation

   Planted foot with twisting of the body around the knee (similar to ACL) Kneecap off to the side Very painful

 MRI

Patellar Dislocation

Patellar Dislocation

 Loose Body – Arthroscopy   Brace?

Rehab  Return to play when comfortable

Osgood-Schlatter Disease

 Jumping sports basketball, volleyball   Dull, aching pain below the knee Bump may be present  Boys 10-16  Girls 9-13

Osgood-Schlatter Disease

 Overuse injury  Traction apophysitis (growth plate)

Osgood-Schlatter Disease

 Overuse injury  Traction apophysitis (growth plate)

Osgood-Schlatter Treatme nt

  NSAIDS Ice  Brace  Relative rest  Full rest  Physical therapy  Knee immobilizer  Cast

Osgood-Schlatter Disease

  Pain usually goes away after the growth plate closes The bump will remain

Meniscus Tear

 History of twisting injury to the knee

Symptoms

  Pain Giving way    Locking Clicking Swelling

Meniscus Tear

 Commonly injured  “Torn cartilage”

Meniscus

 Two C shaped cushions between the thigh and shin bone  Helps knee joint carry weight, glide, and turn

Stress Fracture

  Small incomplete break in bone due to:  Overuse      Poor muscle balance Lack of flexibility Weakness in soft tissue Biomechanical problems Malnutrition Stresses on body are greater than body can compensate  Symptoms    Pain Tenderness after activity

No or little pain in AM, but pain returns after activity

Stress Fractures

 Chronic, overuse injury  Most common in weight bearing bones  Feet, tibia, femoral neck  Seen commonly in Female Athlete Triad (eating disorders, amenorrhea (lack of menstrual periods) & osteoporosis(low bone mass)  Diagnosis by x-ray, bone scan or MRI  Treatment is rest, address biomechanical issues- -some fxs are surgical (e.g. femoral neck)

Return to Running

 Progression of functional activity  Very structured, all timed  Pain & symptoms are to guide progression  Can have frequent setbacks

Return to Running

    Phase I: Walking  30 minutes, aggressive, pain free Phase II: Plyometric Routine  Hopping, 470 foot contacts Phase III: Walk/Jog progression  5 minute/1 minute to 2 minute/4minute Phase IV: Timed Running Schedule  Intermediate & Advanced

Achilles Tendon Rupture

  History  Acute pain in the back of the ankle with contraction, no antecedent history of calf or heal pain  Average age 35  Steroids, fluorquinolones, and chronic overuse may predispose to rupture Pathology  Rupture occurs 3-4 cm above the Achilles insertion in a watershed area

Achilles Tendon Rupture

 Physical Exam      Tenderness over achilles tendon Palpable defect Positive Thompson’s test Needle test- needle inserted midline 10cm proximal to the superior aspect of the calcaneous moves towards the foot when the calf is squeezed No evidence to support routine use of MRI, U/S, or Xray

Achilles Tendon Ruptures

 Surgical repair – Younger active patients  Nonoperative treatment – Older sedentary patients – Patients with increased risk of soft tissue complications     IDDM Smokers Vascular disease BMI > 30

Achilles Tendon Ruptures

 Nonoperative treatment – Weaker tendon – Higher risk re-rupture – Slower return to sport – No surgical morbidity – Lower cost

Indications of Non-Operative Versus Operative Treatment



Indications:

   Non-Operative Tx may be indicated for older patients with minimally displaced ruptures Non-Operative may be indicated for patients who are at an increased operative risk due to age or medical problems Note that younger patients w/ expectations of participating in sports such as basketball may not be good candidates for non operative Tx

Management of Non-Operative Tx

 

Short leg cast strategy (SLC)

  SLC is applied w/ ankle in plantarflexion Cast is brought out of equinus over 8-10 weeks    Following casting, a 2 cm heel lift is worn for an additional 2-4 months

Long leg cast (LLC)

 Walking is allowed (in the cast) at 4-6 weeks Alternatively, consider using functional brace starting in 45 degrees of flexion Initial LLC in gravity equinus for 6 weeks, followed by short leg cast for 4 weeks

Achilles Tendon Rupture



Non-Operative

 Resistance exercises started at 8 weeks   Return to sports in 4 – 6 months May take 12 months to regain maximal plantarflexion power

Clinical Evidence to Support Nonoperative Treatment

     Benefits: no wound complications, no scar, decreased patient cost.

Disadvantage: up to 39% re-rupture rate, increased patient dissatisfaction, decreased power, strength and endurance.

Nistor and later Gilles and Chalmers- non-operative treatment preferred because:    No hospitalizations No wound complications No difference in functional strength Gillies and Chalmers  80% vs. 84.3% return of strength compared to unaffected side, non-op and operative, respectively Wills, 775 patients the overall complication rate of surgically treated Achilles tendon ruptures was 20%.  skin necrosis, wound infection, sural neuromas, adhesions of the scar to the skin, and the usual anesthesia risks

Achilles Tendon Ruptures

 Surgical repair – Superior tendon strength – Lower risk re-rupture (1-3%) – Quicker return to sport – Surgical morbidity    Infection Dehiscence Superficial nerve injury – Increased cost

Achilles Tendon Rupture



Surgical treatment

 Preferred for athletes  Medial incision avoids the sural nerve   Percutaneous vs. Open treatments described Isolate the paratenon as a separate layer

Conclusion

  The current preferred treatment in young and other wise healthy patients is surgical repair Conservative treatment remains an acceptable alternative in older, sick or sedentary patients who have fewer physical demands with limited functional and athletic goals

Lisfranc Injury

  Lisfranc injuries may represent 1% of all orthopedic trauma, but 20% are missed on initial presentation Inability to WB, mid-foot pain, weight bearing x rays are key

Do You Need X-rays

?

X-rays

Treatment

   RICE Bulky Jones dressing or posterior splint NWB on crutches   Frequent neurovascular checks Refer to Ortho

Complications if Missed

    Chronic pain Arthritis Inability to run or jump Acute compartment syndrome

Wrestling

   Bursitis Shoulder injuries Auricular hematomas

  Knee Elbow

Bursitis

  Dislocation Separation

Shoulder Injuries

Shoulder Dislocation

AC Separation

Surgical Repair

 Shoulder dislocation  AC joint repair

Ear Injury

Irritation of the ears can occur to the point that permanent deformity can ensue. Some of these injuries may include:  Cauliflower-ear  Lacerations  Ruptured eardrum  To avoid these problems, special ear guards should be routinely worn.

Auricular Hematoma

  Cauliflower ear Wrestling   1.7-23.4% of all injuries Direct trauma or abrasion  Head or knee   Incidence reduced with headgear 16% (51% to 35%) Only 5% of coaches require headgear at practice

Mouth Guards

 In addition to protecting the teeth, mouth guard absorbs shock and helps to prevent concussions.

Mouth Guards

Correctly fitted mouth guard prevents the majority of dental trauma.  Fit should be:  Tight fit  Be comfortable  Unrestricted breathing  Should not impede speech during competition.

 Fit is best when retained on the upper jaw and projects backward only as far as the last molar.  Composed of a flexible, resilient material.

Cheerleading

Journal of Pediatrics 10/21/12 Academy of Pediatrics Position Paper Sport Designation Better conditioning Availability of trainers Better coaching Undergo Physicals 37,000 ER visits last year

Injuries

Ankle Sprain

  Ligament injury Ankle pain, tenderness, swelling

Ankle Sprain

Treatment

 R.I.C.E. – Rest, Ice, Compression and Elevation   Modify athletic activity

Rehabilitation

ROM

,

strengthening, flexibility, balance  Cooperation and communication between patient, parents, coaches and physician

Wrist Injuries

Ganglion Cysts

Mallet Finger

Finger Dislocations

A dislocation occurs when the normally opposed bones of a joint are separated so that the joint congruity is lost.

Jammed Finger

   Diagnosis only by exclusion.

Jamming force on extended PIP joint.

Diffuse swelling with painful movement.

  R/O fracture, tendon injury Exact pathology is not known.

Jammed Finger

 Bruising of the articular surfaces, secondary effusion and resultant edematous soft tissue swelling most likely sequence of events.

   Prolong morbidity.

Up to 9 months of soreness.

Permanent residual thickening about the joint.

Plantar Fasciitis

   Painful heel “Heel Spur” Microtears of plantar fascia

Plantar Fasciitis

   Heel cups Tape heel, arch Orthotics

Plantar Fasciitis

   Stretch (calf and plantar fascia) Against wall or curb On a step Plantar fascia stretch

Plantar Fasciitis

     Massage may be helpful Warm up well before stretching Ice heel, 20-30 minutes Anti-inflammatories Night splint

Plantar Fasciitis

    Wear good, supporting shoes Arch support Avoid activities that cause heel pain See your physician if pain persists

Shoulder Overuse Injuries

    Tendonitis Overhand sports swimming pitching, serving: (tennis,volleyball), Weight lifting Use proper technique, good supervision

Overuse Injuries

    Reduce Intensity Warm up before Ice afterwards Work with coaches 10% Rule Don’t Increase Activity by More Than 10% Per Week

Conclusion

      Year round conditioning Cross train Warm up/ stretch Use proper equipment Listen to your body Seek medical care if pain continues

Thank you