Sport Injuries

28 October 2013

Sport Injuries
Mohammad Alsofyani
Teaching Assistant – Orthopedic Department

6th MBBS - Surgery Module

1

2

Syllabus
Sport Injuries

Upper Limb

Lower Limb

Impingement
Syndrome

Frozen Shoulder

PCL Injury

Tennis Elbow

Meniscal Injury

Golfer’s Elbow


ACL Injury

Ankle Sprain

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Upper Limb
1.
2.
3.
4.


Impingement Syndrome.
Frozen Shoulder.
Tennis Elbow
Golfer‟s Elbow.

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1. Impingement Syndrome
 Anatomy:
 The shoulder consists of three
bones (humerus, scapula and
clavicle).
 2 joints
(glenohumeral, acromioclavicular
).
 2 articulations
(scapulothoracic, acromiohumer
al) that are joined by several
interconnecting ligaments and
layers of muscles.


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 Anatomy:
 Rotator cuff is a group of muscles and their tendons
that act to stabilize the shoulder.


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Muscle

Origin

Insertion

Action

Nerve Supply

Supraspinatus

Supraspinous
fossa of scapula

Greater
tubercle of
humerus

Abduct the
arm

Suprascapular nerve

Infraspinatus

Infracspinous
fossa of scapula

Greater
tubercle of
humerus

External
rotation

Suprascapular nerve

Teres Minor

Lateral border of
scapula

Greater
tubercle of
humerus

External
rotation

Axillary nerve

Subscapularis

Subscapular
fossa

Lesser tubercle

Internal
rotation

Upper and lower
subscapular nerves


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 Definition: Is a painful disorder which is thought to
arise from repetitive compression or rubbing of
the rotator cuff.


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 Pathophysiology:

Degeneration

Trauma


Vascular
Reaction

Swelling

Impingement

Rotator Cuff
Disruption

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 Grades:
Grade

Age

Cause

Mechanism

Grade I

18 – 30 years

Supraspinatus
tendinitis –
subacromial bursitis

overuse

Grade II

40 – 45 years

Supraspinatus
tendinitis –
subacromial bursitis –
partial tear - fibrosis

Overuse –
degeneration
(Osteoarthritis)

Grade III

Over 45 years

Supraspinatus
tendinitis –
subacromial bursitis –
progressive fibrosis –
disruption of the cuff

Overuse – Fall –
atrophic
degeneration in
the cuff


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 Clinical Features:
 Pain.
 Swelling.
 Limitation of shoulder movement.
 Muscle atrophy.
 Tenderness over greater tuberosity.


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 Diagnosis:

Arthroscopy
Radiological
Examinations
Clinical Examinations

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 Diagnosis:
 Clinical tests:
1. The painful arc: on active abduction, the
pain is aggravated as the arm transverses
an arc between 60° and 120°.

2. The impingement sign: The scapula is
stabilized with one hand while the other
raises the affected arm in flexion,
abduction and internal rotation. The test is
positive when the pain is elicited.


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 Diagnosis:
 Non-invasive:
1. X-ray.
2. MRI.


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 Diagnosis:
 Invasive:
1. Arthrography: Dye is injected into
the glenohumeral joint and
postinjection radiographs are filmed
to assess the integrity of the
glenohumeral joint. If dye escapes
out of the joint and into the
subacromial space, it is diagnostic
of a full-thickness rotator cuff tear.


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 Diagnosis:
 Invasive:
1. Arthroscopy: Minimally invasive visual surgical
procedure to assess shoulder pathology.


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 Management:
 Conservative:
1. It consists of rest, heat, massage, NSAIDs, local
infiltration of hydrocortisone.
2. Exercises both active and passive.
3. Temporary immobilization.


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 Management:
 Operative:
1. Failure of conservative treatment for three months.
2. Patients are young and active.
3. Increase loss of shoulder function.
 Methods:
1. Excision of calcium deposits.
2. Repair of incomplete tear.
3. Acromioplasty.


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2. Frozen Shoulder
(Adhesive Capsulitis)
 Definition: it is a disorder characterized by progressive

pain and stiffness of the shoulder which usually resolves
spontaneously after about 18 months.


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2. Frozen Shoulder
 Etiology: Idiopathic
 Risk Factors:
 Diabetes.
 Dupuytren‟s disease.

 Hyperlipidemia.
 Hyperthyroidism.
 Cardiac disease.
 Hemiplegia.
 After recovery from neurosurgery.


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2. Frozen Shoulder
 Age 40 – 60 years.
 70% of patients are women.
 Pain gradually increases in severity and
often prevents sleeping on the
affected side.
 After several months it begins to
subside.
 Stiffness becomes an increasing
problem, continuing for another 6-12
months after pain has disappeared.


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2. Frozen Shoulder


•Duration 9-15
months.
•Minimal pain
except at end of
ROM.
•Significant
limitation of ROM
with rigid end
feel.

Stage 3 (Thawing or Recovery)

•Duration 1-9
months.
•Pain with active
and passive
ROM.
•Significant
limitation with
flexion, abductio
n, external and
internal rotation.

Stage 2 (Frozen)

Stage 1 (Freezing)

 Stages:

•Duration 15-24
months.
•Minimal pain.
•Progressive
improvement in
ROM

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2. Frozen Shoulder
 Diagnosis:

“Not every stiff or painful shoulder is a frozen shoulder. And
indeed there is some controversy over the criteria for
diagnosing frozen shoulder” (Zuckerman et al., 1994)


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2. Frozen Shoulder
 Diagnosis:
 The diagnosis of frozen shoulder is clinical resting on
two characteristic features:
1. Painful restriction of the movement in the presence
of normal x-rays.

2. A natural progression through three successive
stages.


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2. Frozen Shoulder
 Management:
 Conservative:
1. To relieve pain and prevent further stiffness.
2. Analgesics and anti-inflammatory drugs.
3. Reassure the patient that recovery is certain.
4. Pendulum exercises are encouraged.
5. Once the acute pain has subsided, manipulation
under general anesthesia may improve the range
of movement.


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2. Frozen Shoulder
 Management:
 Operative:
1. Surgery doesn‟t have a well-defined role.
2. The main indication is prolonged and disabling
restriction of movement which fails to respond to
conservative treatment.
3. The rotator interval and coracohumeral ligament
are released and the coracoacromial ligament is
excised.


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3. Tennis Elbow (Lateral
Epicondylitis)
 Definition: Pain and tenderness over the lateral

epicondyle of the elbow (The bony insertion of the
common extensor tendons).


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Epicondylitis)
 Mechanisms: Forceful repetitive wrist extension.


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Epicondylitis)
 Active individual of 30 or 40 years.
 Gradual pain and localized to the lateral
epicondyle.
 The elbow looks normal, and flexion and extension
are full and painless.
 Pain can be elicited by:
1. Extending the elbow.
2. Pronating the forearm.

3. Passively flexing the wrist.


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Epicondylitis)
 Management:
 Conservative:
1. Rest and physiotherapy.
2. Injection of the tender area with
corticosteroid and local anesthetic
relieves pain.
3. Using a brace centered over the
back of your forearm may also help
relieve symptoms of tennis elbow.


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Epicondylitis)
 Management:
 Operative:
1. Persistent of symptoms for 6 to 12 months.
2. A few cases are sufficiently persistent or recurrent.
3. Release of lateral epicondylar muscles.


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4. Golfer‟s Elbow (Medial
Epicondylitis)
 Definition: Is very similar to Tennis Elbow but occurs on
the medial side of the elbow where the flexor origins
are effected.


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Epicondylitis)
 Mechanisms: overuse flingers flexion.


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Epicondylitis)
 Resisted wrist and finger flexion in pronation will
provoke the pain


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Lower Limb
1.
2.
3.
4.


ACL Injury.
PCL Injury.
Meniscal Injury.
Ankle Sprain.

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1. ACL Injury
 Anatomy:
 Origin:
1. Medial and anterior aspect of the
tibial plateau.
 Insertion:
1. Lateral femoral condyle.
 Function:
1. provide approximately 85% of total
restraining force of anterior
translation.
2. Prevents excessive tibial medial
and lateral rotation.


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1. ACL Injury
 Definition: One of the most common knee injuries is
an anterior cruciate ligament sprain or tear.

 Mechanisms:
 Hyperextension force.
 Twisting force on a semiflexed knee.


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1. ACL Injury
 Mechanisms:
 Hyperextension force.


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1. ACL Injury
 Mechanisms:
 Twisting force on a semiflexed knee.


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1. ACL Injury
 Immediately collapse and is painful.
 Popping sensation felt or heard.
 Swelling.
 Giving away.


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1. ACL Injury
 Classification:
 Ligaments sprain are classified in three degrees:
1. 1st Degree: Tear of only a few fibers of the ligament.
Minimal swelling, localized tenderness but little
functional disability.

2. 2nd Degree: Almost all the fibers of a ligament are
disrupted. Pain, swelling and inability to use the
limb. Joint movements are normal.
3. 3rd Degree: complete tear of the ligament


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1. ACL Injury
 Diagnosis:

Arthroscopy
Radiological
Examinations
Clinical Examinations

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1. ACL Injury
 Diagnosis:
 Clinical Examinations:
1. Lachman‟s test.
2. Anterior drawer test.
3. Pivot shift test.


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1. ACL Injury
 Diagnosis:
 Radiological Examinations:
1. Plain X-ray: to demonstrate bone avulsed or
associated fracture.
2. MRI


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1. ACL Injury
 Diagnosis:
 Arthroscopy:
1. May be needed in cases where doubt
persists.


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1. ACL Injury
 Management:
 Conservative:
1. Most cases of grades I and II.
2. The hematoma is aspirated and the knee is
immobilized in a commercially available knee
immobilizer.
3. After a few weeks, the adequate strength can be
regained by physiotherapy.


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1. ACL Injury
 Management:
 Operative:
1. Indicated in multiple ligaments injured
knee, especially in young athletes.
2. Performed 2-3 weeks after injury after acute phase
subsided.
3. Methods:
a) Repair of the ligament: performed for fresh. Additional
reinforcement is provided by a fascial or tendon graft
(Tendon of Hamstring).

b) Reconstruction: in cases of ligament injuries presenting
late.


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2. PCL Injury
 Anatomy:
 Origin:
1. The posterior intercondylar area of
the tibia.
 Insertion:
1. Medial condyle of the femur.
 Function:
1. keeps the tibia from moving
backwards too far.


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2. PCL Injury
 Definition: It is less common than ACL tears.

 Mechanisms:
 Backward force on tibia.


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2. PCL Injury
 Pain with swelling that occurs steadily and quickly
after the injury.
 Swelling that makes the knee stiff and may cause a
limp.

 Difficulty walking.
 The knee feels unstable, like it may "give out”.


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3. Meniscal Injury
 Anatomy:
 The semilunar cartilages are two crescentshaped plates of fibrocartilage placed on
condylar surface of the tibia
 Functions:

1. Increase the stability of the knee.
2. Controlling the complex rolling and
gliding actions of the joint.
3. Distributing load during movement.


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3. Meniscal Injury
 Definition: Medial meniscus is more commonly injured
than the lateral and is usually associated with other
ligament injuries of the knee.

 Mechanisms:
 Medial meniscal:
1. In young: twisting force with the knee bent and
taking weight.
2. In middle age: fibrosis has decreased the mobility
of meniscus and hence tear occurs with less force.


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3. Meniscal Injury
 Mechanisms:


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3. Meniscal Injury
 Classifications


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3. Meniscal Injury
 Usually a young person.
 Pain (usually on the medial side).
 Knee is „locked‟ in partial flexion.
 Sometimes the knee gives way spontaneously.


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3. Meniscal Injury
 Diagnosis:
 Clinical Examinations:
1. McMurray‟s Test.
2. Apley Compression Test.


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3. Meniscal Injury
 Diagnosis:
1. Plain X-ray
2. MRI


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3. Meniscal Injury
 Diagnosis:
 Arthroscopy:
1. May be needed in cases
where doubt persists.


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3. Meniscal Injury
 Management:
 Conservative:
1. Indicated in patients soon after injury with no
locking.
2. If knee is locked, it is manipulated under general
anesthesia.
3. The is immobilized for 2-3 weeks followed by
physiotherapy.


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3. Meniscal Injury
 Management:
 Operative:
1. Indicated if the joint can‟t be unlocked and if
symptoms are recurrent.
2. Closed partial meniscectomy via an arthroscope is
better than total removal of the menisci by open
surgery.


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4. Ankle Sprain
 Anatomy:
 Ligaments of the ankle:
1. Anterior talofibular ligament.
2. Calcaneofibular ligament.
3. Posterior talofibular ligament.


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4. Ankle Sprain
 Definition: Common injury in sport. If
improperly treated it may result in
chronic laxity, pain or delayed
recovery.

 Mechanisms:
 Inversion of supinated planter flexed
foot.


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4. Ankle Sprain
 Anterior talofibular ligament commonly injured
followed by Calcaneofibular ligament.
 The posterior talofibular ligament is rarely sprained.
 Pain, swelling and tenderness over the affected
ligament.


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4. Ankle Sprain
 Diagnosis:
 Clinical:
1. Anterior Drawer Test: If the displacement of talus is
more than 8 mm anterior, it suggests laxity of the
anterior talofibular ligament.


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4. Ankle Sprain
 Diagnosis:
1. X-ray : AP of the ankle to assess talar tilt.
2. Talar tilt test:
 Examiner stabilizes the leg with one hand while inverting
plantar flexed heel with the other hand.
 Alternatively, place the patient's leg in the lateral
position, hanging off the table.
 A strap is applied around the ankle which courses
around the lateral side of the ankle.

 A 4 kg wt is then applied which forces the ankle into
inversion and plantar flexion.


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4. Ankle Sprain
 Diagnosis:
1. Talar tilt test: If the tilt is
more than 5°, it suggests
laxity of anterior talofibular
and calcaneofibular
ligaments


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4. Ankle Sprain
 Management:
 Grade I:
1. Ice therapy, compression bandage, foot
elevation, NSAIDs, are the recommended
treatment.

 Grade II:
1. Long leg cast, range of motion
exercises, strengthening exercises are helpful.
 Grade III:
1. Same lines as mentioned above and sometimes
may require surgical repair.


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Case Study


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History
A 25-year-old man was playing football for his local
team. While going in for a tackle he sustained a
twisting injury to his knee. There was no immediate
swelling. He continued to play for about ten
minutes to the end of the game but then
complained of some pain in the medial aspect of
his knee. He awoke the next day with a painful
swelling in the knee and so consults his general
practitioner.


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Examination
This young man has some mild
swelling,
associated
with
marked tenderness to palpation
over the medial joint line. He has
normal varus/valgus stability of
the knee and a negative
anterior draw and Lachman‟s
test. The range of motion is full. A
plain x ray shows good
preservation
of
the
joint
space, and MRI film is shown.


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Questions
 What is the diagnosis?
 What are the common clinical features of this injury?
 How would you manage this injury?


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References
Textbook of Orthopedics (John Ebnezar).
Aply‟s System of Orthopedics and Fractures.
Essential of Orthopedics (RM Shenoy).
Essential Orthopedics (J.Maheshwari).
Field Guide to Fracture Management (Richard B.
Birrer).
 Current Diagnosis and Treatment of Orthopedic
(Harry B. Skinner).
 Essential Orthopedic and Trauma (David J. Dandy)
 Pocket of Orthopedics and Fractures. (Ronald
McRae).







28 October 2013

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