Sports Sports InjuriesInjuries

Andrew O’BrienTom Milligan

ScenarioScenarioA 40 year old male is asked to play in a work 5 a-side football match. He hasn’t played for a number of years but used to play regular 5 a side in his twenties.

3 minutes into the game he felt he was kicked in the right heel and had to stop playing. The other players denied making any contact at the time. He comes to see you the next day as he has had difficulty walking since.

•What is your provisional diagnosis?•What tests would you perform?

Achilles TendinopathyAchilles Tendinopathy• Previously termed Achilles tendinitis but studies

suggest no prostaglandin mediated inflammation• Term encompasses pain, swelling, weakness and

stiffness of the Achilles• Repeated overloading causes degeneration &

disorganized collagen fibre laydown• Thought to occur when imbalance between

degeneration & repair leading to tearing & pain• Usually occurs at mid-portion of tendon (site of AT

rupture) • Can have associated inflammation of

retrocalcaneal bursa

DiagnosisDiagnosisHistory•Pain in mid portion of tendon•Pain related to exercise (often at start and after exercise with diminished discomfort during exercise)•Stiffness of tendon in morning•Often unaccustomed to or increased intensity of exercise •Can interfere with daily living activityExamination•Look for deformity & swelling•Palpate swelling, nodularity, heat and creps.•Exclude rupture

ManagementManagement• Expectation 3-6 months to resolve• Discontinue quinolones/consider steroid use• Initial period rest until pain subsides• NSAIDS should be limited to 14 days use• AT stretching exercises• DO NOT Inject tendon• Consider referral to physio for biomechanical

assessment• Consider referral to MSK or ortho’s if not settled

at 3-6 months

StretcheStretchess AT stretches: hold

for 30 secs, rpt x3, twice daily

Wall Push Ups: try and hold lean for 30 secs, x 10, Twice daily

Stair stretch: 30 seconds x 6, twice daily

Spiderman RehabSpiderman Rehab

Management In Management In Secondary CareSecondary Care

• Extracorporeal shock wave therapy• Iontophoresis, phonophoresis, sclerosant, GTN

patch, growth factor injections all have weak evidence.

• Surgery – includes nodule & adhesion excision, longitudinal incision.

Achilles Tendon Achilles Tendon Rupture Rupture

Predisposing Factors•Age 30 – 50•Steroids•Fluoroquinolones•Tendinopathy•Haglunds Deformity•Running Sports

HistoryHistory• Abrupt change of direction

• Often Patient unaccustomed to sport

• Often patient thinks struck at back of ankle

DiagnosisDiagnosis• Simmonds/

Thompsons/Squeeze Test

• Palpation - Rupture at 3 to 6cm

TreatmentTreatment• All Cases Referred to

Orthopaedics

• Treatment Equinus casting vs Surgical repair

• Decision depends on patient choice and activity level

Scenario 2Scenario 2A 17 year old girl comes to see you c/o pain in her lower legs. She has been in the school athletics team for 4 years and has recently started training for the london marathon. She says she has pain in her lower legs and points to the middle 1/3 of her tibias. It comes on if she runs any more than 4 or 5 miles and can last for days after the runYou note she is tender on the medial border of her tibias in the mid/upper 1/3What advice would you give and what is your management plan?

Shin SplintsShin Splints• Medial Tibial Stress Syndrome/Shin Splints• Not Specific Diagnosis - Refers to pain along the

course of the tibia• Cause is thought to be related to overloading

muscles of the lower limb and biomechanical irregularities

• Encompasses 3 main entities:1. Medial Tibial Stress Syndrome2. Chronic compartment syndrome3. Tibial stress fracture

MTSSMTSS• Most Common Running injury – accounts 15%• Inflammation of tendon insertions to tibial

periosteum• Pain is in distribution of Sharpey Fibres that

connect Soleus fascia through periosteum of tibia• Increased foot pronation, varus tendancy of

forefoot, increased strength of plantar flexors, inadequate Ca intake, hard or inclined running surfaces, inadequate shoes and previous injury all implicated

MTSS Risk FactorsMTSS Risk Factors• Repetitive trauma sports e.g. running &

gymnastics• Female• Low aerobic fitness• Over Pronation Feet• Tight calf muscles• Sudden Increases activity level

MTSSMTSS

• MTSS consequence of repetitive stress by impact forces that fatigue soleus

• Causes bending or bowing of Tibia overloading bone remodeling capabilities of Tibia

• Stress microfractures can be created which aren’t seen on XRAY

DiagnosisDiagnosis• History • Examnation – tenderness of

tibia• XRAY • CT/MRI

ManagementManagement• Shock Absorbent insoles• Control overpronation • Training Error Avoidance• Rest (up to 3/12)• Crutches• NSAIDS• Physio for lower limb muscle strengthening and

graduated training programs.

Knee Sports injuries

• Aimso To have a working knowledge of knee anatomy to explain common injuries

to patientso To appropriately refer knee meniscal injurieso Be aware of patella tendonitis

• Objectiveso Be able to draw a schematic diagram of a kneeo To be able to diagnose meniscal injuries and know the difference between

sports injuries and fragility tearso Know Diagnosis and treatment for patella tendonitis.

Anatomy

Case 1• A 23 year old footballer has had a twisting injury

to the knee which has now locked and become swollen. He can weight-bare with pain. You see him a week after the injury.

• What do you want to know?• What treatments are available?• Are the treatment different if he were 60?

Meniscus Injuries• Are there mechanical symptoms• Fragility tear or not

• Referral Options:o Haemarthrosiso Arthroscopy without imagingo Imaging

Case 2• An 13 year old boy has persistent pain in his knee

following a minor trauma two weeks ago. You can find no locking, effusion, instability. He can walk with minor discomfort. Would you:

• A. Wait and see• B. Refer to physio• C. X-ray

Case 3• 25 year old man with anterior knee pain. When

you examine him he can straight leg raise, has no effusion or locking or crepitus but has point tenderness on the distal pole of the patella.

• What is wrong?• How do we treat this?

• http://www.youtube.com/watch?v=hqNC3sXzJII&feature=relmfu

• http://www.youtube.com/watch?v=ul09qA4hJQg&feature=related

Patella tendinitis• One of the commonest tendinopathies• Rest, Ice, NSAIDS, Stretches before future

exercise• Eccentric loading exercises• Refer to physio.

Question Session