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SPORTS INJURY JAIPUR TALK

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SPORTS INJURIES HAMSTRING ACL OVERHEAD ATHELTE

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SPORTS INJURY JAIPUR TALK

  1. 1. SPORTS INJURIES Dr.RAJAT JANGIR Consultant Arthroscopy and Sports Injury Ligament and Joints Clinic, Mansarovar, Jaipur MS Ortho (Ahmedabad) Fellow Arthroscopy(S.Korea) Dip Sports Med IOC
  2. 2. Sports for Health
  3. 3. But for some people—particularly those who overdo or who don’t properly train or warm up—these benefits can come at a price: sports injuries.
  4. 4. Knee injuries (55%) >Shoulder> Ankle The most common injuries are  strains or sprains (41%),  broken bones (20%),  bruises or superficial injuries (19%)
  5. 5. India: Data Sparse  Journal of Athletic Enhancement: Prevalence of Sports Injuries in Adolescent Athletes Ieleni Sreekaarini, KMC Manipal
  6. 6. Sports injury pattern in school going children Chandigarh Dr.Ravi Gupta
  7. 7. French gymnast Samir Ait Said snapped his leg during a pommel horse
  8. 8. Australian javelin thrower Kim Mickle dislocated her right shoulder
  9. 9. Ankle Sprain
  10. 10. German Gymnast Adreas TOBA
  11. 11. The ‘immediate’ cause may seem obvious  but sports medicine clinicians think beyond the ‘immediate cause’
  12. 12. Treatment ABC  Airway  Breathing  Circulation
  13. 13. Initial treatment of injuries PRICE  Protection  Rest  Ice  Compression  Elevation
  14. 14. Protection  Take player away from field to avoid further injury as soon as possible
  15. 15. Rest  Remove player from field  Rest injured area  Immobilize area  Why?  Reduces further tissue damage  Reduces blood flow  Allows for full assessment of injury
  16. 16. Ice  Ice bag, pack  Ice water bath  15 mins/ 5 times a day  Why?  Cool the area which constricts blood vessels, reduces blood flow and fluid leakage, less swelling, pressures and pain
  17. 17. Compression Compress injured area with Elastic bandage Move distal to proximal Why? External pressure reduces fluid leakage and bleeding into tissues Provide support the area
  18. 18. Elevation  Elevate area above height  Why?  Reduces bleeding as blood has to flow up hill  Gravity helps swelling to move towards lymph nodes
  19. 19. No HEAT  Includes  Hot packs  Spas  Saunas  Why?  Increases blood flow to area therefore increases swelling
  20. 20. No ALCOHOL  Includes most things adults enjoy after a game of sports  Why?  Thins blood which increases swelling  Adds toxins to already injured area
  21. 21. No RUNNING  Includes running as well as any exercise that is painful  Why?  Increases in tissue damage  Overload to other area as compensation
  22. 22. No MASSAGE  Rub down  Massage  Mobilizations  Why?  May increases tissue damage  Increases blood circulation to the injured area
  23. 23.  Overhead Athelete  Hamstring strain  Plantar Fascitis  Ankle Sprain  ACL Injury
  24. 24. Who is an Overhead Athlete?
  25. 25. Kinetic chain Mc Mullen and Uhl 2000
  26. 26. Lesions • Specific to the overhead athlete - Internal impingement - UPS (Unstable Painful Shoulder) • Not specific to the overhead athlete - SLAP tears - Anterior Instability - Sub-acromial impingement - Fractures/ dislocations
  27. 27. Internal Impingement
  28. 28. Pathology • Cardinal lesions • Articular sided rotator cuff tears • Postero-superior labral lesions • Landmark article: Walch G, Boileau P, Noel E, et al. Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: an arthroscopic study. J Shoulder Elbow Surg. 1992;1:238-245.
  29. 29. Symptoms ation • Pain during maximal abduction/ external rot • Posterior joint line / shoulder girdle pain • Progressive decrease in velocity. Loss of control / performance. • Symptoms of anterior instability (?)
  30. 30. Signs • Posterior glenohumeral joint-line tenderness • Loss of Internal Rotation • Excessive External rotation • Special tests - for SLAP, biceps, Cuff and instability
  31. 31. Specific test • Internal impingement test • Place arm in Abduction 90-110, Max ER, Ext 10-15. • Deep posterior shoulder pain • In non contact injuries; 95% sensitivity, 100% specificity Meister K, Buckley B, Batts J. The posterior impingement sign: diagnosis of rotator cuff and posterior labral tears secondary to internal impingement in overhand athletes. Am J Orthop. 2004;33:412-415.
  32. 32. Specific test • Jobe’s Relocation test • Abduction and external rotation causes posterior joint line pain. • relieved by anterior pressure
  33. 33. UPS
  34. 34. UPS: Unstable Painful shoulder • Symptoms of pain • No symptoms of instability. • Imaging / Arthroscopy suggestive of instability • Apprehension test caused pain Retrospective Mean 38 months FU • 95% satisfied 75% return to sports. The unstable painful shoulder (UPS) as a cause of pain from Unrecognized Anteroinferior instability in the young athlete. J Shoulder Elbow Surg. 2011 Jan;20(1):98-106. Boileau P, Zumstein M, Balg F, Penington S, Bicknell RT. Hôpital de L'Archet, Nice, France.
  35. 35. Surgeon’s perspective
  36. 36. Decision making • Level of participation • Sport • Motivation • Season Surgeon Therapist Coach Patient
  37. 37. Beware! !• Cuff tears in asymptomatic individuals • Labral tears in asymptomatic athletes ! • Pathologies which do not corelate with clinical picture ! • Low sensitivity of scans to pick PT cuff tears Avoid Excessive reliance on scans
  38. 38. Role of surgery • After exhausting rehab options. • “Trial of Therapy” vs “early surgery” = overuse vs acute trauma
  39. 39. Rehab • Core Strength • Scapular dyskinesia • Manage Internal rotation deficit • Restore RC force couple
  40. 40. Surgical input Precision strike and not carpet bombing!
  41. 41. Hamstring strain  Lateral: Biceps femoris (BF) lh – sh  Medial:  Semimembranosus (SM)  Semitendinosus (ST) Tendon insertion  Proximal conjoined of ST and BF(A)  SM long prox tendon (B) • Distal insertions Lateral lh-BF • Fibular head Medial SM: deep, flat, wide ST: superficial
  42. 42. Injury types  Direct injury – Contusion – Laceration  Indirect injury (muscle strain) Most common in sports High recurrence rate
  43. 43. Indirect injury  High speed(1) – Eccentric  Combination?  Slowstretch(2) Passive outer range stretch – Prolonged recovery time
  44. 44. Diagnosis  Inspection  Pain on: – Stretch – Contraction – Palpation (83% BF LH, 12% SM, 5% ST*)  Additional imaging may guide diagnosis and prognosis#
  45. 45. MRI or US?  Ultrasound Low costs Dynamic imaging  MRI More sensitive small/deep lesions Less rater dependent
  46. 46.  MRI indication and timing: experts opinion < 3 days trauma MRI preferred ‘by experts and literature for acute hamstring injuries in elite athletes based on its greater sensitivity for minor injuries’ Kerkhoffs et al. 2012
  47. 47. History Positive parameters  Moderate evidence: • Shorter self predicted time to RTP  Limited evidence: • Shorter time to RTP predicted by the clinician
  48. 48. Negative history parameters  Limited evidence: • Type of sport (dancers vs sprinters)  • Higher VAS score at injury  Conflicting evidence: • Stretching type of injury mechanism (vs. sprinting type) • ≥ 1 day to walk pain free
  49. 49. Advise for daily practice, reporting MRI  Absence of edema (Grade 0 quicker RTP),  Grade 3 delayed RTP  Involvement of proximal tendon (and describe the central tendon)
  50. 50. Therapy  Physical therapy / rehabilitation  Additional medical therapies  Surgery
  51. 51. Return to play  Decision affects: Athlete’s availability Performance Re-injury rate  Clinician reputation
  52. 52. Return to play • No consensus about safely RTP • No single test as the gold standard. Orchard J, Best TM, Verrall GM. Return to play following muscle strains. Clin J Sport Med Off J Can Acad Sport Med 2005;15:436–41. Heiderscheit BC, Sherry MA, Silder A, et al. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther 2010;40:67–81. Mendiguchia J, Brughelli M. A return-to-sport algorithm for acute hamstring injuries. Phys Ther Sport 2011;12:2–14.
  53. 53.  Can we use MRI for RTP decision making ?  Follow-up MRI has been suggested to support decisions
  54. 54. Plantar Fasciitis  Gradual onset of deep, aching heel pain localized to the plantar medial heel  AM pain on arising & after getting up from sitting  Start-up pain improves after ambulation but may worsen w/ prolonged activity
  55. 55. Plantar Fasciitis Risk Factors  Repetitive stress in athletes  Obesity  Cavus foot – accommodates poorly to stresses  Over-pronated pes planus – excessive laxity stresses the PF  Tight heel cord  Heel spur: Often coincidental  NOT itself the etiologic factor Occurs in FDB, not the PF
  56. 56. Plantar Fasciitis Non-op Treatment  Successful in more than 90% of patients  Complete relief of symptoms may take months to > 1 yr  Achilles tendon & PF stretching (latter more effective)  Heel cushions/ Shoe inserts / orthoses  Activity modification Oral NSAIDs
  57. 57. Plantar Fasciitis Non-op Treatment If no improvement after 6 – 8 weeks  Night splints  Casting  Steroid injection  After weeks to months w/o improvement  Limit to2 or 3as may weaken PF & resulting rupture  Avoid injecting the fat pad as atrophy may result  Consider w/u for rheumatologist
  58. 58. Plantar Fasciitis OPERATIVE Treatment  AOFAS position statement recommends min 6 mo and preferably 12 mo nonoperative treatment  Subtotal PF release ± decompression of first branch of lateral plantar nerve  Complete release → iatrogenic flat foot w/ lateral midfoot pain  Endoscopic release limited
  59. 59. ANKLE SPRAIN
  60. 60. ACL
  61. 61. “Matched Anatomic” Single Bundle
  62. 62. Advantages- Anatomic Reconstruction  Supplementing both AM & PL  Controlling both AP & Rotatory Instability  Drilling femoral Tunnel Independently of tibial tunnel
  63. 63. All Inside
  64. 64. ADVANTAGES  LESS PAIN  QUICKER RECOVERY  INSTRUMENTATION SPECIFICALLY DESIGNED FACILITATE A MORE PREDICTABLY ANATOMIC ACL RECONSTRUCTION  Disadvantages  INCREASED COSTS DUE TO THE SPECIAL INSTRUMENTS  TECHNICALLY DEMANDING WITH LEARNING CURVE FOR SUGEON

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