Sports Med

Acute injury

single trauma that happens in an instance due to extrinsic and intrinsic causes

Extrinsic causes

Direct, forceful blows

high velocity impacts

high energy collsions

Intrinsic causes

Injury results from joint loadings

Open kinetic chain

Closed Kinetic chain

Injury occurs some distance from impact e.g. FOOSH causing radial fracture

Closed Kinetic Chain

where kinetic energy is fixed to an object e.g. arm wrestling

Open Kinetic Chain

where kinetic energy is not fixed to an object or the ground e.g. squats

Overuse injuries

result from repetitive micro traumatic tissue damage

Clinical Grading of sprains

1. fibre overstretching (mild injury)

2. rupture of fibres (moderate injury)

3. total ligament rupture (severe injury)

What does this line graph show

Shows how an increased load increases deformation

2-4% on this graph

known as the linear phase, where when stretching stops, the ligament will come back to its normal position - no damage has occurred

Between 4-6%

overstretching occurs, and when releasing the ligament back - it doesn’t go back to it’s 100% lengthening position - it is a little overstretched

6%

starts to rupture and snap - it wont go back to its original position as it has damaged fibres - sit longer than original position - plastic deformation

8%

elongation, total ligament rupture

Ligament Sprain Grading

Grade I, II, III

Grade I of Ligament Sprain

• localised palpation tenderness

• minimal swelling

• normal ROM/ end-feel (stops movement)

• little functional deficit - can do normal walking

Grade II of Ligament Sprain

• notable palpation tenderness

• can be considerable swelling

• increased joint laxity - not as stiff or firm as before injury (increased movement)

• positive end-feel - it would still stop the joint from excess movement

• moderate functional deficit - can’t do normal things as running and jumping compared to before injury

Grade III of Ligament Sprain

• audible pop - sometimes occurs

• immediate pain (then maybe none) - occurs cause it snaps connections to the spinal cord and therefore no recording of pain after the immediate pain

• significant palpation tenderness - all the tissues around the fibre is painful

• major swelling (haemarthrosis) - not all instances

• significant joint laxity no end-feel - complete excess movement, nothing stopping the excess movement occurring

• significant functional deficit - e.g. ACL injury (knee is unstable, collapse, unable to bend knee)

Lateral Ankle Sprain Grading

Based on ankle function, joint testing, pain, swelling, ROM

Grade I, II, III

Grade I of Lateral Ligament Sprain

• no point tenderness or loss of function -

• little haemorrhaging, swelling (<0.5cm) or decreased total ankle ROM (<5 degrees)

• no ligamentous laxity (negative anterior drawer and talar tilt tests)

• Negative anterior drawer test - mainly ATFL, draging heel forward

• Talar Tilt Test - mainly CFL but exclusive, tilting foot inwards

ATFL

Anterior talofibular ligament

CFL

Calcaneofibular ligament

Grade II of Lateral Ligament Sprain

• point tenderness, some loss of function

• swelling (>0.5, <2.0cm), decreased ROM (>5 but <10 degrees) - more laxity

• positive anterior drawer test but negative talar tilt test

  • positive anterior drawer test shows a lot more ankle movement forward, showing that the ATFL isn’t restriciting that motion compared to normal movement - damaged fibres

Grade III of Lateral Ligament Sprain

• extreme point tenderness, haemorrhage ~ extreme loss of function - off load weight to other leg, hopping, don’t want to get up

• decreased total ankle motion >10 degrees and swelling >2.0cm

• positive anterior drawer and talar tilt tests

  • positive both tests suggest ATFL and CTL involvement, increased laxity

Expected Recovery for Lateral Ankle Sprain per Grade

• Return to play for athletes: symptom and function based (not time-based) is best practice - can they walk, hop, calf raises correctly without pain

• Grade I: 7-10 days

• Grade II: 2-4 weeks

• Grade III: 5-10 weeks (Chorley 1997

Medial Ankle Sprain

Eversion, injury to deltoid ligament due to high forces

Types of Medial Ankle Sprain

Partial, Complete, High Sprain

Partial Medial Ankle Sprain

• superficial (weak) bands

  • tibiocalcaneal

  • tibiospring

  • tibioanvicular

Complete Medial Ankle Sprain

• involves deep (strong) bands:

  • anterior tibiotalar

  • deep posterior tibiotalar

High Ankle Sprain characteristics

• rupture of tibiofibular syndesmosis

• anterior inferior tibiofibular ligament (AITFL)

• loaded dorsiflexion, external tibial rotation

• distal separation (diastasis) of the tibia and fibula

• ~15% of all ankle sprains

• Maisonneuve fracture of fibula - fracture of fibula in the mid-shin area

• stable sprain - conservative management - “the norm”

• unstable sprain - operative management

• Return to play (RTP) conservative = 42 +- 10 days

• RTP surgical = 55 +- 11 days

`Single Isolated Sprain

Injury may be localised to individual ligament such as ATFL or MCL and typically conservative management is used for ATFL/MCL injuries even with Grade III injuries

Dislocation

complete dislocation of articulating joint surfaces

Subluxation

partial dislocation where the bones are misaligned but still attached

Minor joint Dislocations

fingers - proximal interphalageal (PIP) joint dislocation most frequent due to ball sports, and toes - 2nd toe most frequently dislocated

Patellar Dislocation

• direct impact or non-contact

• 99% lateral displacement

• high female to low male ratio (10:1)

• patella alta (long patellar tendon)

• trochlea dysplasia (shallow, hypoplasia)

Shoulder Dislocation

• ~50% of dislocations visits to emergency

• ~95% anterior dislocation

Hip Dislocation

• rare

• ~90% posterior dislocation (femur adducted internally rotated

• commonly associated with femoral head and neck fractures

• long-term sequelae include post-traumatic OA- osteoarthritis - and osteonecrosis (onset 2-5 years)

  • osteonecrosis = when bone tissue dies due to poor blood supply

TFCC Injury

Triangular Fibrocartilage Complex - located in wrist

• area that has cartilage, bone ligament

• this area absorbs ~20% axial load across wrist joint

• acute injury increasingly recognised in athletes and distal radio-ulnar joint instability

• FOOSH (fall on outstretched hand), compressive loading injuries (gymnastics, weight-lifting, racket sports)

Scapholunate dissociation

• injury to scapholunate ligament (in wrist) - ligament is important for wrist stability, functionality and grip-strength

• FOOSH injury complication

• ~15% distal radius fractures associated with scapholunate dissociation - large enough force to cause a fracture leads to a tear of dissociation

• Wattson test - rolling wrist laterally, if it clunks or doesn’t move smoothly, it shows disruption in the wrist

• commonest form of carpal instability

• ligament reconstruction to return grip strength / pain relief

• development of wrist OA / SLAC scapholunate advanced collapse wrist

• people with this dissociation go on to have severe osteoarthritis and severe problems with wrist and hand movement

Sternoclavicular joint injury

• anterior dislocation more common

  • medial end clavicle can be palpable and prominent

  • subluxations after failed healing of ligamentous structures

• posterior (retrosternal) dislocations

  • ~30% associated with injury to brachial plexus, great vessels, trachea

Pubic Symphysis Diastasis

• occurs with forceful impacts

  • horse riders landing astride saddly pommel with very high vertical force

  • traumatic, painful separation of pubic fibrocartilaginous joint

• damage / rupture stabilising ligaments

  • splitting triangular inferior pubic (arcuate) ligament, superior pubic ligament

  • large diastasis requires stabilisation - repiar surgically

Muscle Strains

muscle fibres / tissues fail under imposed demands

Hamstring Strain Characteristics

• lateral strains : commonest

  • 83% bicep femoris

  • 12% semimembranosus

  • 5% semitendiosus

• reinjury: ~20% AFL, ~16% NFL, soccer

Clinical era of Grading Muscle Strains

three-tiered system with increasing severity ( minor - Grade i, moderate - Grade II, severe - grade III)

Grade I Muscle Strain

• localised pain - small number of fibres ruptured

• no strength loss

• no swelling

Grade II Muscle strain

• pain limited motion

• swelling

• large number of fibres ruptured

• reduced strength

Grade III Muscle Strain

• visual defect

• complete tear

• significant strength loss

BAMIC (Hamstring Tears)

British Athletics Muscle Injury Classification is based on tissue injury, location of injury and size of injury

1. Small injuries

2. Moderate injuries

3. Extensive Tears

4. Complete tears

a. myofascial

b. musculotendious

c. infratendious

Type I

Type II

Difference between RTP for bicep femoris central tendon disruption and non-central tendon disruption

• central tendon disruption: 72 days RTP

• no central tendon disruption: 21 days RTP

Type I of Hamstring Strains

• high speed running - most common injury mechanism

• ling head of biceps femoris - proximal muscle tendon junction

• rehabilitation time for Type 1 strains, typically less than type II

• increased RTP: Type I biceps femoris long head intratendinous “C” injuries

If you have an intratendinous tear, RTP rapidly increases compared to myofascial or musculotendious tears

Type II of Hamstring Strains

• stretch-related injury mechanism

• medial hamstring strain: semimembranosus

• proximal free tendon of semimembranosus injury near ischial tuberosity insertion

• rehabilitation commonly longer than type I hamstring strain (except if type I is intratendinous)

Muscle lesion sites and %

• myotendinous: 68%

• isolated muscles: 12%

• myofascial: 32%

• maybe more than 1 site simultaneously

Risk Factors in Muscle Strains

• hamstring injury reoccurrence rate HIGH

• previous injury

• biarticular anatomy

• Large deceleration/ Eccentric forces:

• Neural Activation - ‘mis-timing’ of muscle contractions

• Fibre type proportions

• “Strength” Imbalances / Deficits

• Anatomical Characteristics:

• Age (difficult to define ‘older’ athlete)

Fractures

Break in bone, range from minor to major injuries

Internal trauma for fractures

twisting

external trauma for fractures

• high force, speed, collisions

• direct, forceful blows

• impact vulnerable / unprotected sites- when your not expecting so you don’t tense or prepare

Closed fractures

no jagged edges point out through the skin

Classifications of closed fractures

• define them based on:

  • angulation

  • non-displaced. vs displaced

  • stable vs unstable

Types of Closed Fractures

Transverse

Linear

Oblique non-displaced and displaced

spiral

greenstick

comminuted

Open Fractures

Also known as compound fractures. Definition: a fractures with jagged edges pointing out through the skin

Characteristics of Compound Fractures

defined by:

• infection

• vascular/neural injuries

• definitive medical management

Greenstick Factures

A fracture that occurs typically in children in which bone is bent enough o crack one side without snapping into multiple pieces - generally painful, swollen but stable

Fracture peak in adolescents

girls - 11-12yr, boys - 13-15yr - coincides with PHV, precedes by ~1yr peak bone mineral accrual

Growth Plate Injuries

A fracture that occurs in soft-cartilage area at the end of child’s long bones - typically 15-30% of childhood fractures

Growth Plate Injuries Characteristics

• ccur twice as often in boys as in girls

• most heal without complications with proper treatment

• serious problems rare but can occur

• most commonly occur with trauma although slipped upper femoral epiphysis (SUFE) can occur without acute trauma

• salter-harris classification of physeal injuries

SALTER Classification for Growth Plate injuries

S = Straight across

A = Above - most common

L = beLow

T = thorough

ER = cRushed or ERasure - least common

Avulsion Fractures

when fractures result in bone fragment being torn off at tendon (muscular) or ligament attachment sites, 3-5 times more likely in young males and commonly occurs at the base of 5th metatarsal

Bone Bruising

Microtrabecular fracture that is associated with marrow oedema. Interosseous bruise = bleeding inside bone marrow while subchondral bruise = between cartilage and bone beneath causes cartilage to separate bone

Periosteal Contusion

crushing of periosteum between bone and hard object and direct impact at vulnerable sites such as iliac crest. Maybe accompanied by surrounding soft-tissue damage and normally has a palpable lump that is inflamed and irritated

Tendon Rupture

when tissue loading capacity is exceeded by abnormal or unexpected laoding, resulting in rupture of tendon

Types of tendon rupture

Partial, complete and achilles tendon rupture

Partial Tendon Rupture

• small to large number of ruptured fibres

• pain

• limited function

• still intact

Complete rupture

• total disruption of tendon

• pain and non-function of specific muscle-tendon unit

Achilles Tendon Rupture

most commonly ruptured tendon, 10 x more males rupture achilles tendon compared to females and extreme muscle-tendon CSA ratio - normal ratio is 34:1, achilles tendon can be 300:1, because achilles acts like a spring

Grading for Achilles Tendon Rupture

• I = partial ruptures <50% conservative

• II = complete rupture gap <3cm anastomosis

• III = complete rupture gap 3-6cm tendon graft

• IV = complete rupture defect of >6cm graft and gastrocnemius recession

Tenden Avulsion

detachment of tendon - extrinsic forces

jersey finger

• when finger gets caught in someones jersey and snaps tendon

  • flexor digitorum profundus detachment

  • cannot flex finger

Tendon Displacement

• displacement /bowstringing of finger flexor tendons from tear of pulleys

• common finger injury in rock climbers

• A2/A4 pulley injuries most common

  • pain, loud pop

  • loss of motion and grip strength - function of tendon is compromised

Acute joint injuries

traumatic ligament, meniscal, labral, cartilage, bone damage which leads to osteoarthritis and may have increased intra-articular fluid - depends on what is damaged

acute articular cartilage injuries

where cartilage chips off the bone, use MRI, CT detection of injuries

micro-fracturing

type of arthroscopic surgery, pokes into the bone of the chipped area - suppose to help with the vascular supply to the surface and re-growth of cartilage

mosaicplasty

type of arthroscopic surgery, types cartilage from the bone to cover up the current hole

acute muscle contusions

a painful injury caused by a direct blow or impact that damages muscle fibers and connective tissue, leading to internal bleeding and swelling

Mild “Cork”

• usually able to continue playing

• soreness after cooling down or following day

• RTP ~ 1-3 weeks

Moderate “Cork”

• (RTP ~4+ weeks)

  • may prevent player from continuing, minimum stiffening/ swelling may be experienced with rest

  • ROM will be diminished up to 50%

Severe “Cork”

• rapid onset of swelling and obvious bleeding

• movement loss severe, difficulty bearing full weight on affected leg, muscle strength diminished

• RTP ~ up to 8 weeks

Timeline and visual deficits of acute muscle contorsions

• initially red ( fresh, oxygen-rich blood newly pooled underneath skin)

• after 1-2 days, blood loss oxygen - appear blue, purple or black (haemoglobin)

• after 5-10 days, yellow/ green (bilirubin)

• after 10-14 days, yellowish brown or light brown

Myositis Ossificans Traumatica

condition where bone forms abnormally within a muscle or soft tissue, usually as a result of trauma, and can lead to pain, swelling, and limited movement. Occurs due to differentiation of fibroblasts into osteoblasts. surgery does not work as the bone will regrow back

compartment syndrome

painful condition where increased pressure within a muscle compartment restricts blood flow, potentially causing permanent damage if not treated promptly

Exercise-Associated Muscle Cramps (EAMC)

painful, involuntary muscle contractions that occur during or shortly after exercise

Exercise-Associated Muscle Cramps (EAMC) Symptoms and common muscles

• painful, spasmodic, involuntary contractions

• 1-3 minute duration

• late in game or post-exercise

• common muscles

  • calf (gastrocnemius)

  • foot (intrinsic muscles)

  • thigh (quads and hamstrings)

Management of EAMC

• passive stretching - most effective treatment for relief

  • may increase tension in GTO - inhabitation to increase afferent reflex inhibition to alpha motor neuron

• symptomatic relief within 10 to 20 secs

  • maintain stretch until fascilation ceases

• pickle juice

  • decrease in cramp duration due to activation of oropharyngeal reflex - reduce alpha motor neuron activity of cramping muscles

  • gargle or swallow

Acute DOMS

delayed onset muscle soreness following vigorous, unaccustomed exercise, normally 24 - 48hrs after exercise, particularly eccentric actions

Signs and Symptoms of DOMS

• pain after unaccustomed eccentric exercise peaks at 24-72 hrs

• local muscle swelling / muscle stiffness

• muscle strength deficits

• elevated plasma creatine kinase - marker of muscle breakdown

Management for DOMS

• during symptomatic period (up to 10 days) modify exercise regime

• massage, stretching, active recovery may provide relief

• turmeric may reduce inflammation and pain by modulating inflammation

• protective effect conferred by repeated eccentric bouts

Process of DOMS

microtrauma of muscle cells and connective tissue followed by local inflammatory process within extracellular space which sensitives nerve ending

Stages of Overuse injuries

1. pain in affected area after exercise

2. pain during exercise not restricting performance

3. pain during exercise, restricting performance

4. chronic, persistent pain, even at rest

Failed healing of overuse injuries

strong structures eventually become cartilage - less strong

Overuse Tendinopathy

injury where the tendon is repeatedly strained until tiny tears form. Increases vessels and nerves in the muscle (they will get squeezed leading to internal bleeding), increased collagen disorganisation, tendon degeneration (long-term) and inflammation (short-term)

Extrinsic factors for overuse injuries

• training and technique errors e.g. going from 0 to 100 for beginner runners instead of slowing increasing running into walking routine

• surfaces and shoes e.g. going from grass to hard concrete without slowly easing into it

• equipment

Intrinsic Factors for overuse injuries

• previous injury

• “flexibility”

• leg length discrepance - e.g. one leg is longer than the other

• mal-alignment - tibial torsion / vara and genu valgum / varum

• mal-tracking- knee moving out of align in end of ROM

• patella alta

• q-angle

• pes planus

• pes cavus

• overpronation

• muscle weakness

Running Injuries

• patellofemoral pain syndrome (PFP)

• Achilles tendinopathy

• medial tibial stress syndrome (MTSS)

• Plantar fasciitis