DAVID C. KORONKIEWICZ, D.O. IU GOSHEN ORTHOPEDICS & SPORTS MEDICINE SPORTS INJURIES Indiana...
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Transcript of DAVID C. KORONKIEWICZ, D.O. IU GOSHEN ORTHOPEDICS & SPORTS MEDICINE SPORTS INJURIES Indiana...
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