Common Sports Injuries 1 PDF

Mr Gavin Brown Senior clinical lecturer Consultant orthopaedic surgeon Body in Motion MBChB Common sports injuries 1 1 ...

Mr Gavin Brown Senior clinical lecturer Consultant orthopaedic surgeon Body in Motion MBChB Common sports injuries 1 1  Body in Motion MBChB Content Sport injuries Part 1 Paediatric injuries Upper limb injuries Part 2 Lower limb injuries To keep the videos to a manageable length, this topic has been split into 2 parts. In this video, we’ll look at a couple of sports conditions that occur in children and young adults, then look at some common upper limb injuries in adults. In the next video, we’ll then look at sports injuries of the lower limbs. 2  Body in Motion MBChB Apophyseal injuries Sport injuries Apophysis Secondary ossification centre Site of tendon insertion into bone Acute avulsion Sudden, forcefull contraction ‘Snap’ or ‘pop’ As we’ve learned in the bone formation video, children’s bones have primary and secondary centres of ossification. The secondary ossification centres are located away from the articular surface and occur at sites where a tendon inserts into bone, such as the abductor muscles of the hip inserting onto the greater trochanter. In children and adolescents, the secondary ossification centres haven’t fused to the rest of the bone yet and are instead only connected by cartilage. This means they are a relative weak point in the bone, which is often weaker than the tendon that attaches to it. If a sudden, forcefull contraction of a muscle occurs then its tendon can pull or ‘avulse’ the apophysis from it’s position on the rest of the bone. The patient will usually feel this as a sudden snapping or popping sensation at the site of avulsion, with pain and weakness of the affected muscle. The image on the right shows the apophyses around the hip and pelvis, with the relevant muscle attachments labelled. 3  Body in Motion MBChB Apophyseal injuries Sport injuries Apophysis Secondary ossification centre Site of tendon insertion into bone Acute avulsion Sudden, forcefull contraction ‘Snap’ or ‘pop’ Radiograph or MRI Case courtesy of Dr Andrew Mark Holland Dixon,, Radiopaedia.org, rID: 19164 30012 Investigation of apophyseal avulsions uses plain radiographs in the first instance and MRI scans if a diagnosis is unclear. Some avulsions can be fairly obvious, like this LT avulsion due to iliopsoas contraction, but some can be a bit more subtle, like this ischial tuberosity avulsion from hamstring contraction. 4  Body in Motion MBChB Apophyseal injuries Sport injuries Apophysis Secondary ossification centre Site of tendon insertion into bone Acute avulsion Sudden, forcefull contraction ‘Snap’ or ‘pop’ Radiograph or MRI Treatment Rest, protected weight bearing, early ROM and stretching Surgery indicated rarely (displacement >3cm) Treatment of avulsions is almost always conservative with rest, protected weight bearing with crutches, early active motion exercises and passive stretching. In some rare cases where the fragment is large and very displaced, operative fixation may be indicated. 5  Body in Motion MBChB Chronic apophysitis Sport injuries Osgood-Schlatter’s disease (tib tuberosity) Sinding-Larsen-Johansson (inferior pole of patella) Sever’s disease (calcaneus) Radiographs and MRI Management Rest NSAIDs Stretches Activity modification Repeated microtrauma to an apophysis can cause a spectrum of pathology, with inflammation in the local area or fragmentation of the apophysis itself. There are lots of eponymous terms for the various different locations where these occur with the most common being Osgood Schlatter’s disease of the tibial tuberosity, Sinding Larsen johansen disease of the inferior pole of the patella, and sever’s disease of the calcaneus. Diagnosis combines physical exam findings of localised tenderness and pain on resisted muscle contraction, with investigations of plain radiographs and MRI. Like most chronic overuse injuries, management is conservative with rest, NSAIDs, stretches and activity modification. 6  Body in Motion MBChB Shoulder dislocations Sport injuries Common during contact sports Can lead to long term instability Young athletes with traumatic dislocations High chance of repeat dislocations Often need stabilisation surgery We’ll now move on to discuss look at some adult upper limb sports conditions, starting with a very common problem in contact sports, that of shoulder dislocation. This injury can cause long term instability, with repeat dislocations increasingly likely in young athletes who continue to play contact sports. This high risk of dislocations means many young athletes end up having stabilisation surgery that trades range of motion in the joint for increased stability. 7  Sternoclavicular joint Acromioclavicular joint Glenohumeral joint Most people think of the shoulder as the joint between the humeral head and the glenoid, the glenohumeral joint, but shoulder movement also involves 2 other joints, which are the acromioclavicular and sternoclavicular joints. The scapula floats on top of the muscles of the thorax and so called scapulothoracic movement contributes significantly to range of motion. This means the upper limb’s only bony connection to the axial skeleton is through the clavicle via the AC and SC joints. 8  Deltoid Pectoralis Major and Minor Biceps Brachii The muscles important for shoulder stability and movement are, from the anterior; The deltoid, the pectoralis major and minor, and the biceps 9  Supraspinatus Subscapularis Biceps long head Biceps short head Biceps has a short head which originates from the coracoid and the long head which originates from the superior glenoid rim and runs down through the biceps groove between the greater and lesser tuberosities of the humeral head. We can see a couple of the rotator cuff muscles here, subscapularis, which sits deep to the scapula and acts to internally rotate the shoulder, and supraspinatus, passing through the subacromial space to abduct the shoulder. 10  Supraspinatus Infraspinatus Teres minor From posterior we can see supraspinatus a bit more clearly in the fossa above the scapular spine. The last 2 rotator cuff muscles are also visible; infraspinatus and teres minor, which are both external rotators. 11  Body in Motion MBChB Sport injuries Glenoid Capsule LHB tendon Infraspinatus Labrum Humeral head Subscapularis If we take an axial slice through the mid-shoulder, that is to look at it from above, we can see how the anatomy of the joint also contributes to its wide range of motion. Unlike the deep cup of the acetabulum in the hip, the glenoid is more of a shallow bowl or plate. This means the bones of the glenohumeral joint have minimal contribution to stability, which in stead relies mainly on the soft-tissues. The biceps tendon and the muscles of the rotator cuff, only 2 of which are shown here, pull the humeral head against the glenoid. The glenoid labrum, a tough ring of cartilage on the glenoid rim, deepens the shallow bowl of the glenoid. The joint capsule prevents the shoulder from getting into extreme positions and is reinforced by thickened bands on its anterior and posterior surfaces, called the glenohumeral ligaments. The shoulder is a joint that has evolved to trade stability for range of motion and the pathologies we’ll discuss next reflect this. 12  Body in Motion MBChB Sport injuries Shoulder dislocation is the most obvious presentation of shoulder instability. Dislocation can be in one of 3 directions: The most common is anterior, when the humeral head dislocates anteriorly and usually slightly inferiorly. Posterior dislocations are relatively rare and occur with extreme muscle contractions, such as during a seizure or an electrocution. The humeral head rotates posteriorly and can be difficult to diagnose on radiographs, which we’ll see in the next section. A third type of dislocation, known as luxatio erecta, is when the humeral head is levered out with hyperabduction and becomes trapped inferior to the glenoid. This only occurs with high energy trauma so is the rarest type of dislocation. 13  Body in Motion MBChB Sport injuries An acute, anterior dislocation of a shoulder is often a fairly obvious diagnosis, as seen here, with a squared off appearance to the shoulder and the arm held in adduction and internal rotation. It’s important to test the sensation of the axilliary nerve, over the lateral shoulder, as this can commonly be injured in acute dislocations. 14 Investigating acute dislocations is primarily performed by plain radiographs. This radiograph demonstrates an anteriorly dislocated shoulder, with a soft tissue shadow showing the squared‐off appearance and the humeral head sitting anterior to the glenoid. Although only 1 view is shown here, it’s important to obtain at least 1 additional view, like a scapular Y view or axilliary shoot through. 15  Case courtesy of Radswiki, Radiopaedia.org, rID- 11813 Posterior dislocations are more difficult to diagnose and are frequently missed. Obtaining a second view can ensure this does not happen. 16  Body in Motion MBChB Sport injuries For the rest of the tutorial, we’ll mainly discuss anterior dislocations, as they account for the vast majority of cases. When the humeral head dislocates anteriorly, it can cause injury to itself, the glenoid or the surrounding soft tissues. 17  Body in Motion MBChB Sport injuries Hill-Sachs lesion Posterolateral humeral head Compression fracture Bankart lesion Anterior glenoid rim Bony or labral A Hill-Sachs lesion is a compression fracture to the posterolateral humeral head, when it is crushed against the anterior glenoid rim. I like to think of it like pressing your finger into a ping-pong ball and leaving a divot, as the surface of the bone is impacted but remains intact due to the overlying cartlilage. Complimentary to this is the Bankart lesion, when the humeral head either fractures the edge of the glenoid rim or rips throught the anterior labrum. My analogy here is like breaking off the edge of a plate, which means it’s not able to hold its contents properly any more. 18  Body in Motion MBChB Sport injuries Reduce Restrict Rehabilitate Images from aofoundation.org Treatment of an acute dislocation follows three main steps First the shoulder is relocated back into joint, known as reduction. There are many ways described but the most common, and certainly my preference, is with longitudinal traction, with or without lateral force on the humeral head. Sedation and muscle relaxants are given to avoid fighting against the patients own muscle power. After the shoulder is reduced, a short period of restricted movement is needed in a shoulder immobiliser. This allows the patient’s pain to settle and the soft tissues to recover but should not be done for an extended period, usually no more than 2 weeks. Early range of motion exercises with physiotherapy are crucial to return strength to the dynamic stabilisers of the shoulder. 19  Body in Motion MBChB Elbow epicondylitis Sport injuries Medial or lateral side Majority can be treated conservatively Moving down the arm, another common sports pathology are the chronic overuse injuries of the medial or lateral elbow epicondyles. Keeping with the norm for chronic overuse injuries, these can mostly be treated conservatively. 20  Body in Motion MBChB Sport injuries Medial supracondylar ridge Pronator teres Medial epicondyle Flexor carpi radialis Palmaris longus Flexor carpi ulnaris Flexor digitorum superficialis Having some knowledge of which muscles originate from which side of the elbow gives a clue as to the mechanisms that cause epicondylitis. On the medial side of the elbow is the flexor-pronator mass. The pronator teres muscle arises from the supracondylar ridge. This muscle, as its name suggests, pronates the forearm. The medial condyle itself, gives rise to the common flexor tendon, which is the origin of most of the flexors of the wrist and hand. These muscles are FCR, PL, FCU and, not shown here as it is a deeper structure, FDS. You can see here how all the muscle origins are bunched together around the prominence of the medial epicondyle 21  Body in Motion MBChB Sport injuries Lateral supracondylar ridge Extensor carpi radialis longus Lateral epicondyle Anconius Extensor carpi ulnaris Extensor digitorum Extensor carpi radialis brevis Extensor digiti minimi Supinator All of the wrist and hand extensors originate from around the lateral epicondyle. On the supracondylar ridge is ECRL, which extends the wrist, and arising from the lateral epicondyle itself are anconius, ECU, ED and ECRB. 2 further muscles are deep to these, the EDM and supinator. Again, you can see here how close they originate to one another. 22  Body in Motion Lateral epicondylitis MBChB Sport injuries Overuse of common extensor origin Repeated microtrauma → inflammation ECRB usually involved Repetitive wrist extension 50% of tennis players develop (backhand) Repetitive gripping or lifting Eg, hammer Pain ECRB origin Resisted wrist/finger extension Passive wrist flexion in pronation Radial tunnel syndrome Wikimedia commons: Richard Thorpe [CC BY-SA 2.0] Epicondylitis can affect either the medial or lateral side of the elbow. Lateral epicondylitis is more commonly know as tennis elbow while medial epicondylitis is known as golfers elbow. While lateral is most common in tennis players, it is not exclusively to this sport as they can be affected by golfers elbow and visa versa. It is an overuse injury of the common extensor origin, which results in repeated microtrauma, usually to the ECRB origin, and subsequent inflammation. Activities that involve repetitive wrist extension, gripping and heavy lifting are the common causes, with about half of professional tennis players developing symptoms, probably due to their backhand swing. Aditional risk factors for tennis players include; poor swing technique, a heavy racket, incorrect grip size and high string tension. A patient with suspected lateral epicondylitis will have pain directly over the ECRB origin, just over or above the lateral epicondyle, and pain on actions that stretch the common extensor origin, such as resisted wrist and finger extension or passive flexion of the wrist with the forearm pronated. They may also complain of deep aching pain in the dorsoradial forearm, which is a sign of radial tunnel syndrome due to compression of posterior interosseous nerve 23  Body in Motion Medial epicondylitis MBChB Sport injuries Much less common than lateral Overuse of flexor-pronator mass Repetitive wrist flexion/forearm pronation Golf, baseball, racquet sports Jobs requiring force grip, heavy lifting Plumber, carpenter, construction Pain 1cm distal/anterior to med epicondyle Resisted wrist flexion/pronation Ulnar neuritis Paraesthesia in ring/small finger Wikimedia commons: Mat8877 [CC BY-SA 4.0] Medial epidondylitis is much less common than lateral but shares much of the same pathophysiology. Its also an overuse injury but of the flexor-pronator mass and is caused by sports which require repetitive wrist flexion and forearm pronation and jobs requiring force grip and heavy lifting. You can see how there is significant cross-over in causes and it’s not uncommon to have both lateral and medial epicondylitis concurrently. The pain in these patients is elicited by palpation 1cm distal and anterior to the medial epicondyle and is exacerbated by resisted wrist flexion and pronation. These patients may have an ulnar neuritis, as the nerve passes between the muscles, and may demonstrate paraesthesia in the ring and small fingers. 24  Body in Motion Epicondylitis investigation MBChB Sport injuries Primarily history and physical exam Plain radiographs Usually normal May show calcification L M Ultrasound Dynamic test High accuracy (operator dependant) MRI Evaluate other pathologies Diagnosis of epicondylitis is primarily done through a good history and physical exam. Radiographs are usually unremarkable but may show calcification of the the affected tendons. Ultrasound can be of great use for both sides as it is dynamic and very accurate in experienced hands. MRI scans are useful to evaluate other pathologies, such as ulnar collateral ligament injuries in overhead throwers or ruptures of the pronator origin. 25  Body in Motion Epicondylitis management MBChB Sport injuries Conservative Surgical 90% success Open debridement/release 1st line management Failed non-op (6-12/12) Rest – avoid activity 6-12/52 Ice Good to excellent outcomes L M Passive stretching Medial < lateral Bracing Worse if neural involvement NSAIDs Extracorporial shockwave US to tissues transdermally Corticosteroids Side-effects Treatment for epicondylitis is much the same for both sides and has excellent outcomes for 1st line conservative management. This involves activity modifications like avoiding exacerbating activies for 3-6 months and assessment of swing technique and racquet set-up. Physiotherapy, bracing and non-steroidal analgesia are also important parts and, when all aspects are adhered to rigorously, give a 90% plus success rate. Other possible non-operative treatments are extra-corporeal shockwave therapy, when uss energy is delivered through the skin to the affected tissues. This is thought to promote angiogenesis, tendon healing and give short term analgesia, although there are no real guidelines on when to use it. Corticosteroids injections have some benefit in reducing inflammation but have significant potential side-effects, suchs as tendon weakening, nerve injury and skin pigmentation. Surgical management is usually reserved for patients who have failed conservative management after a prolonged period. The operation involves open debridement of the inflamed tendon tissue, re-attachment of the affected muscles and release of nerves if trapped. It has good to excellent outcomes in 80-90% of patients, although is less successful in lateral epicondylitis or if there is neural involvement. 26  Body in Motion MBChB Content Sport injuries Paediatric Apophyseal avulsions and chronic apophysitis Upper limb Shoulder dislocation Epicondylitis That brings us to the end of the first part of this topic, where we covered apophyseal avulsions, chronic apophysistis, shoulder dislocation and elbow epicondylitis. We’ll move on to discuss the lower limb in the nexrt video. 27 Mr Gavin Brown Senior clinical lecturer Consultant orthopaedic surgeon Body in Motion MBChB Common sports injuries 2 1  Body in Motion MBChB Content Sport injuries Part 1 Paediatric injuries Upper limb injuries Part 2 Lower limb injuries In part 1 of this topic, we discussed sports pathologies of children and the adult upper limb. In part 2, we’ll look at pathologies of the adult lower limb. 2  Body in Motion MBChB Sprains and strains Sport injuries Groin Hamstring Ankle Sprains and strains are one of the most common injuries sustained during sport, second only to cutaneous injuries like cuts and bruises. Sprains are injuries to ligaments, like the ligaments of the ankle, and occur during sudden stretching of ligaments past their elastic limit, deforming or tearing them. Strains are injuries to muscle fibers or tendons, which anchor muscles to bones. Strains are called “pulled muscles” for a reason: Over-stretching or overusing a muscle causes tears in the muscle fibers or tendons. Think of ligaments and muscle-tendon units like springs. The tissue lengthens with stress and returns to its normal length — unless it is pulled too far out of its normal range. Common sites of sprains and strains are the groin, for the hip adductors, the hamstrings and the ankle. All are treated with rest, ice, activity modification and early RoM excercises. Repeated or severe injuries to the ankle ligaments can result in chronic instability that, like shoulder instability, can require stabilisation surgery. 3  Body in Motion MBChB Soft-tissue knee injuries Sport injuries Meniscal injuries ACL PCL Collaterals Combo Soft tissue injuries to the knee are very common in high impact sports, both contact and non-contact, and include injuries to the ligaments and menisci. It’s quite common for injuries to exist in combination, for example an ACL tear with a co-existing meniscal tear, and some can be quite catastrophic, like the multi-ligamentous knee injuries sometimes suffered from a knee dislocation. 4  Body in Motion MBChB Meniscal tears anterior Sport injuries Functions Force transmission Stability Medial Meniscus Semi-circular Attached to MCL Less mobile Lateral Meniscus Circular More mobile posterior When looking at the tibia from above, the 2 menisci appear as c-shaped structures which sit on top of the tibial condyles. They are made of fibrocartilage, which is very tough when compared with the soft hyaline cartilage of the articular surface. They have 2 main functions, namely to transmit force evenly across the knee and to increase knee stability. The functional anatomy tutorial goes into a bit more detail of how they achieve this. The medial meniscus has a more semi-circular shape while the lateral is more circular and covers more of the tibial articular surface. They are attached to the tibia by their anterior and posterior horns, with the attachment points shown here in green. At its periphery, the medial meniscus is attached to the joint capsule and the medial collateral ligament making it much less mobile than the lateral meniscus, which is not attached to the lateral collateral. This relative immobility of the medial meniscus makes it more prone to injury. 5  Body in Motion Meniscal tears MBChB Sport injuries History Examination Twisting injury Localised joint line tenderness Most sensitive Swelling Effusion Delayed or intermittent swelling Sweep Immediate may indicate ACL/PCL Patellar tap Localised pain Specific tests Mechanical symptoms Low sensitivity/specificity Locking McMurray’s Giving way Apley’s compression ‘Clicking’ Signs of other injuries Ligamentous Fracture A good history and exam can give clues to the presence of meniscal injury. Asking about the injury itself may yield a typical history of twisting injury, with swelling that came on at least 30 minutes or so afterwards. If immediate swelling and an inability to play on are reported then the likelihood of a cruciate ligament tear is raised. The patient may report pain that is localized to one side of the the knee and may describe classic mechanical symptoms of locking, giving way and clicking noises or sensations. True locking is a mechanical block to fully extending the knee, as opposed to pseudo- locking from muscle spasm, and indicates there is a displaced meniscal tear which is trapped between the joint surfaces. Examining the patient with a meniscal tear will usually identify localized joint line tenderness over the affected side and is the most sensitive test. Depending on how recent the injury is, most patients will have some degree of joint effusion, which is picked up by the sweep test and patellar tap. Many specific tests have been described for meniscal tears, such as McMurray’s and Apley’s compression test, but all have proved over time to be of only modest value due to low sensitivity and specificity. Finally, it’s important to look for signs of other knee injuries like cruciate ligament tears and fractures. 6  Body in Motion MBChB Meniscal tears Sport injuries Plain radiographs Exclude other injuries MRI Gold standard High sensitivity/specificity Quality of meniscal tissue Articular surfaces Associated pathology James Ellisbjohns Case courtesy of Dr Varun Babu, Radiopaedia.org,Heilman, rID:[Public MDdomain] 57386 [CC BY- SA 4.0)] Once a meniscal injury is suspected there are 2 main investigations that should be performed. Although plain radiographs have little benefit in diagnosing meniscal injuries, they are important as a first line investigation to exclude other injuries such as a tibial plateau fracture or more subtle things like the Segond fracture, which is pathognomonic of an ACL rupture. Really any suspicion of a meniscal tear should be investigated with an MRI scan, as it is the gold standard test. Although it relies on the skill of the reporting radiologist and quality of scanner, it is at least 90% accurate with high sensitivity and specificity. It also looks at the whole knee and gives information about the quality of both the meniscal and articular cartilage as well as diagnosing other pathology such as ligamentous injuries. 7  Body in Motion MBChB Meniscal tears Sport injuries Conservative management First-line treatment for degenerative tears Surgery has poor outcome Symptom control Analgesia (Non-steroidal anti-inflammatories) Rehabilitation Physiotherapy Image from Summit Medical Group Management of meniscal tears and be split into 3 broad categories: rehabilitation, removal, and repair. Although the choice of treatment is fundamentally down to patient preferences, there are a few factors to consider when giving advice on surgical over conservative management. Degenerate tears are much less likely to have good outcomes with surgery so conservative management is the mainstay of treatment. Small tears in the red‐red zone can also be treated conservatively as they are most likely to heal on their own, without surgical intervention. Management here consists mainly of symptom control, with non‐steroidal analgesia, and extensive physiotherapy rehab to strengthen the knee muscles and return proprioception. 8  Body in Motion Meniscal tears MBChB Sport injuries Surgical management Removal Repair Partial menisectomy Red-red zone Irreparable Longitudinal tear Failed repair ACL-repair at same time Total menisectomy