77 Pathology in the Athlete (Dikis 2024) PDF

Introduction Athlete ath·lete | \ ˈath-ˌlēt noun a person who is proficient in sports and other forms of physical exercise. Introduction Injuries to the foot and ankle during athletic activities are a common occurrence, representing approximately 25% of all sports injuries seen in sports medicine sp...

Introduction Athlete ath·lete | \ ˈath-ˌlēt noun a person who is proficient in sports and other forms of physical exercise. Introduction Injuries to the foot and ankle during athletic activities are a common occurrence, representing approximately 25% of all sports injuries seen in sports medicine specialty clinics INTRODUCTION Beyond usual treatment protocol ○ High physical demands ○ Specialized per sport Understanding of necessary steps to not only heal, but to return to sport INTRODUCTION Individualized rehabilitation program Specific protocols lacking, few validated Difficult to confidently ensure safe return to sport introduction Running One of the worlds most popular forms of exercise Incidence of lower extremity injury ○ 20-80% Multifactorial introduction Age Gender Anatomy Stretching Shoe Foot type Nutrition and supplementation Common injuries in athletes Overuse injuries ○ Anterior Tibial Stress Syndrome (ATSS) ○ Medial Tibial Stress Syndrome (MTSS) ○ Plantar fasciitis ○ Stress fractures ○ ITBS ○ Patellofemoral syndrome Chronic exertional compartment syndrome Midfoot sprain/Lisfranc injuries Turf toe Ankle sprain – lateral or high Jones fracture Common injuries in athletes Medial Tibial Stress / Anterior Tibial Stress Syndrome AKA “Shin splints” Commonly seen in novice athletes Periostitis secondary to traction ○ Bony resorption that outpaces bone formation of the tibial cortex Common injuries in athletes Numerous factors involved: ○ Gastrosoleal tightness ○ Deep posterior muscle group weakness ○ Tibial varum ○ Improper biomechanics External rotation hip ○ ○ ○ Training on hard surfaces Training errors High body mass index Common injuries in athletes Medial Tibial Stress / Anterior Tibial Stress Syndrome Symptoms include: ○ Pain initially while running, improving with time ○ Pain resumes upon stopping ○ Pain localized to the lower third of the posterior medial surface of the tibia ○ Pain localized to anterior lower leg Pronated foot type? Common injuries in athletes Medial Tibial Stress / Anterior Tibial Stress Syndrome Treatment ○ Initially aimed at reducing pain and inflammation ○ Relative rest Cross-training ○ Physical therapy modalities ○ Foot orthoses ○ Core strengthening ○ Gradual return to activity Common injuries in athletes Medial Tibial Stress / Anterior Tibial Stress Syndrome Treatment: ○ When acute pain has resolved Strength and proprioception for weakened posterior muscle groups Barefoot exercises to maintain intrinsic musculature ○ Nielsen et al Increasing mileage by less than 10% per week lead to fewer injuries in novice runners Common injuries in athletes Medial Tibial Stress / Anterior Tibial Stress Syndrome Treatment: Common injuries in athletes Stress Fractures Recall lecture by Dr. Nelson in CPMD Tibia most commonly involved in athletes (49%) ○ Followed by tarsal bones 25% ○ Bilateral 16% Concern that may progress to complete fracture Common injuries in athletes Stress Fractures Differentiate from ATSS/MTSS ○ Focal pain with stress fracture ○ Diffuse pain with ATSS/MTSS ○ Will determine if continuing running vs cross-training ○ Can occur concomitantly! Common injuries in athletes Stress Fractures Overuse typically indicated, but intrinsic factors also involved: ○ Poor BMD ○ Low body weight ○ Biomechanical abnormality Common injuries in athletes Stress Fractures High index of suspicion required Often hurts more as the activity continues, relieved with rest Hop test X-rays ○ Negative ○ Navicular, cuboid Common injuries in athletes Stress Fractures Advanced imaging ○ Bone scan ○ MRI ○ CT Particularly useful in tarsal bones Common injuries in athletes Stress Fractures If it hurts, don’t do it Navicular stress fractures most common in runners ○ Painful only with running or on toes Delays diagnosis, up to 9 months in literature ○ More aggressive nonsurgical management necessary Anterior tibial stress fractures ○ Notoriously slow to heal Common injuries in athletes Stress Fractures Treatment ○ Offloading based on pain level ○ Follow clinical symptoms above all else ○ Maintaining fitness ○ Adjunct therapies Common injuries in athletes Stress Fractures Surgery proposed for ○ Displaced navicular stress fractures ○ Nondisplaced complete fractures with sclerotic changes ○ Comminuted fractures ○ Athletes who fail conservative management or who cannot tolerate a prolonged recovery course Common injuries in athletes Stress Fractures ○ Saxena & Fullem Compared group of non-op and ORIF 4.0 months return to activity Surgery considered for more severe injuries Common injuries in athletes Stress Fractures ○ Saxena & Fullem Common injuries in athletes Chronic Exertional Compartment Syndrome (CECS) Increased intracompartmental pressure ○ Impedes local tissue perfusion ○ Muscle ischemia and pain True prevalence unknown ○ Likely underdiagnosed Most often seen in runners or other highly active individuals Common injuries in athletes Chronic Exertional Compartment Syndrome (CECS) Most commonly occurs in leg ○ Anterior compartment Gradually increasing pain with activity in specific area of the leg or foot ○ Aching, squeezing, cramping, tightness Common injuries in athletes Chronic Exertional Compartment Syndrome (CECS) Reproducibility is one of most distinctive clinical characteristics Paresthesia, foot drop Common injuries in athletes Chronic Exertional Compartment Syndrome (CECS) Obtain x-rays to rule out other pathology No noninvasive measurement technique has been accepted as an equivalent alternative to direct pressure measurement. No agreed upon standard for performing intracompartmental pressure (ICP) testing Common injuries in athletes Chronic Exertional Compartment Syndrome (CECS) Pedowitz et al ○ One or more of the following present: Pre-exercise pressure ≥ 15mmHg One-minute post-exercise pressure ≥ 30mmHg Five-minute post-exercise pressure ≥ 20mmHg Common injuries in athletes Chronic Exertional Compartment Syndrome (CECS) Treatment ○ Non-surgical: Change in running surface Orthotics Reduced training volume PT Ice Common injuries in athletes Chronic Exertional Compartment Syndrome (CECS) Treatment ○ Surgical: Compartment release – fasciotomy 70-80% return to sport/activity Common injuries in athletes Acute Ankle Sprain ○ Upwards of 30% of injuries seen in sports med clinics ○ Lateral collateral ligaments most commonly affected (ATFL, CFL) ○ High ankle sprain = inferior tibiofibular syndesmotic ligaments ○ Difficult to determine time for return to sport ○ Controversies in treatment Common injuries in athletes Acute Ankle Sprain ○ ○ ○ Determine severity Exam Pain to palpation Instability Imaging Early weightbearing Surgery can play a role in cases of instability Common injuries in athletes Many factors will influence healing rate in athletes ○ Degree of injury ○ Prior level of conditioning ○ Age ○ Sport ○ Motivation level ○ Access to specialty treatment Goals of rehabilitation 01 Decrease pain 05 Improve gait pattern and closed kinetic chain motion 02 Reduction or elimination of edema 06 Minimize risk of reinjury 03 Restoration of unrestricted ROM 07 Sports-specific agility drills 04 Regain necessary strength 08 Maintain cardiovascular fitness Approach to the injured athlete Approach to the injured athlete Platelet-Rich Plasma (PRP) Enhance tissue regeneration Remains controversial No absolute indication currently for use in foot and ankle Considered as alternative when all other nonsurgical options have been exhausted summary Sport-specific considerations Conditions reviewed: o MTSS/ATSS o CECS o Stress fracture o High ankle sprain Approach and goals of treatment references Meehan et al. “Chronic Exertional Compartment Syndrome” UptoDate 2022. B Fullem. “Overuse Lower Extremity Injuries in Sports” Clin Podiatr Med Surg 32 (2015) 239–251. A Kor. “Dynamic Techniques for Clinical Assessment of the Athlete” Clin Podiatr Med Surg 32 (2015) 217–229. Saxena & Fullem. “Navicular Stress Fractures: A Prospective Study on Athletes” FAI 2006; (27)11. Saxena et al. “Treatment of Medial Tibial Stress Syndrome With Radial Soundwave Therapy in Elite Athletes: Current Evidence, Report on Two Cases, and Proposed Treatment Regimen” JFAS 2017; 56: 985-989. Saxena et al. “Navicular Stress Fracture Outcomes in Athletes: Analysis of 62 Injuries” JFAS 2017; 56: 943-948. Velasco & Leggit. “Chronic Exertional Compartment Syndrome: A Clinical Update” Curr Sports Med Rep 2020; 19(9): 347-352. THANKS! Copyright Notice: This presentation may contain copyrighted material used for educational purposes under the guidelines of Fair Use and the TEACH Act. It is intended only for use by students enrolled in this course. 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