DAVID C. KORONKIEWICZ, D.O.IU GOSHEN ORTHOPEDICS &

SPORTS MEDICINE

SPORTS INJURIES

Indiana Osteopathic Association32nd Annual Winter Update

December 6,2013

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 quicklyRunning or jumping on hard surfacesTraining vigorously without adequate restPoorly functioning equipmentImproper techniquesWorking through painLack of stretching/strengthening

When to See the Physician

Decreased ability to playInability to playLimp, loss of motion or swellingVisible deformitySevere pain

Injury Classifications

Sprains: injuries to ligamentsStrains: injuries to muscles, tendons or

the junction between the twoContusions: 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 rulesWear appropriate protective gearKnow how to use equipmentNever “play through pain”

Skilled sport specific instruction

Year round conditioning

Preventing Sports Injuries

Make Sure Your AthletesAlways Warm Up First!

Preventing Sports Injuries

Preventing Sports Injuries

Break a sweatMarchingWalk in placeJumping jacksMimic the sport you

are about to do

WARM UP

Breathe slowly and deeply

Relax into the stretch

Should not feel painAvoid bouncingHold stretch 30

secondsStretch both sides

Stretching

Stretching:

Injuries

MOST COMMON

Strains & Sprains

THIS

NOT THAT

Strain

StrainOverstretching of a muscle

Caused by overexertion or by lifting Frequent site is the Back

Strains

Signs & SymptomsLocalized swellingCrampingInflammationLoss of functionPainGeneral weaknessDiscoloration

PreventionProper warm-upStretchProper mechanicsProper cool-down/

stretchProper 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

SprainInjury 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 sprainRest and limited or no movement of the affected

partIce to reduce swelling and painCompression with elastic bandage to control

swellingElevation of the affected part Obtain medical help if swelling is severe or if

there is any question of a fracture

Contusion

BruiseSudden traumatic

blow to body (severe compression force)

Usually injury to blood vessels under skin

Speed of healing depends on tissue damage and internal bleeding

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

movementTreatment

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

SubluxationOccurs when bone

displaces and partially separates

DislocationExcessive 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

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

Why are Injuries on the Rise?

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 kneeNon-contact injury,

with foot plantLanding on straight legMaking 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 sizeIntercondylar

notch size

Extrinsic factors: Conditioning Experience Skill StrengthMuscle

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

MRI

ACL

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 muscleAvulsion of adductor

or sartorius musclePubic ramus fractureFemoral neck fractureFemoral shaft fractureSI joint subluxationRuptured 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/surgeryFemoral neck

fracture-surgeryCross trainProper nutrition and

calories

Complications if Missed

Stress to complete fracture

Avascular necrosisChronic painEnd of career

Patellofemoral Pain Syndrome

Anterior knee painProbably 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

Patellar Dislocation

MRI

Patellar Dislocation

Loose Body – Arthroscopy

Brace?RehabReturn to play

when comfortable

Osgood-Schlatter Disease

Jumping sports-basketball, volleyball

Dull, aching pain below the knee

Bump may be presentBoys 10-16Girls 9-13

Osgood-Schlatter Disease

Overuse injuryTraction

apophysitis (growth plate)

Osgood-Schlatter Disease

Overuse injuryTraction

apophysitis (growth plate)

Osgood-Schlatter Treatment

NSAIDSIceBraceRelative restFull restPhysical therapyKnee immobilizerCast

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 SymptomsPainGiving wayLockingClickingSwelling

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 injuryMost 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 MRITreatment is rest, address biomechanical

issues---some fxs are surgical (e.g. femoral neck)

Return to Running

Progression of functional activityVery structured, all timedPain & symptoms are to guide

progressionCan 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 rupturePathology

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

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

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 Walking is allowed (in the cast) at 4-6 weeks Alternatively, consider using functional brace

starting in 45 degrees of flexion Following casting, a 2 cm heel lift is worn for

an additional 2-4 monthsLong leg cast (LLC)

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

RICEBulky Jones

dressing or posterior splint

NWB on crutchesFrequent

neurovascular checks

Refer to Ortho

Complications if Missed

Chronic painArthritisInability to run or

jumpAcute

compartment syndrome

Wrestling

BursitisShoulder injuriesAuricular hematomas

Bursitis

KneeElbow

Shoulder Injuries

DislocationSeparation

Shoulder Dislocation

AC Separation

Surgical RepairShoulder 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 LacerationsRuptured eardrum

To avoid these problems, special ear guards should be routinely worn.

Auricular Hematoma

Cauliflower earWrestling

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

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

Mouth Guards

Mouth Guards

Correctly fitted mouth guard prevents the majority of dental trauma.

Fit should be:Tight fitBe comfortableUnrestricted breathingShould 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 10/21/12Academy of Pediatrics Position Paper

Sport Designation

Better conditioningAvailability of

trainersBetter

coachingUndergo Physicals

37,000 ER visits last year

Injuries

Ankle Sprain

Ligament injuryAnkle pain, tenderness, swelling

Ankle Sprain

Treatment

R.I.C.E. – Rest, Ice, Compression and Elevation

Modify athletic activityRehabilitation 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 cupsTape heel, archOrthotics

Plantar Fasciitis

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

Plantar Fasciitis

Massage may be helpfulWarm up well before stretchingIce heel, 20-30 minutesAnti-inflammatoriesNight splint

Plantar Fasciitis

Wear good, supporting shoesArch supportAvoid activities that cause heel painSee your physician if pain persists

Shoulder Overuse Injuries

TendonitisOverhand sports-

pitching, serving: (tennis,volleyball), swimming

Weight liftingUse proper

technique, good supervision

Overuse Injuries

Reduce IntensityWarm up beforeIce afterwardsWork with coaches

10% RuleDon’t Increase Activity by More Than 10% Per

Week

Conclusion

Year round conditioningCross trainWarm up/ stretchUse proper equipmentListen to your bodySeek medical care if pain continues

Thank you

THE END