DR.NORLELAWATI BINTI MOHAMAD

SPORTS PHYSICIAN

HOSPITAL SULTAN ISMAIL

Pre SEA Games Training : Management of Sports Injury Conference

2016

Any physical complaint sustained by a

patient that results from

sports/exercise participation

irrespective of time loss from

sports/exercise activities.

*Various way to classify the sports injury, based on:

*Mechanism/Causes of injury

-Direct

-Indirect

-Overuse

*Onset of symptoms

-Acute

-Chronic

*Structural involved

-Bone

-Ligament

-Tendons

-Muscles

Causes of

injury

Direct OveruseIndirect

Direct injury-caused by an external blow or force

-i.e :- a collision with another person

-being struck with an object (for example, a

cricket ball or hockey stick).

Indirect injury can occur in 2 ways:

- The actual injury can occur some distance from the

impact site.( i.e falling on an outstretched hand can result

in a dislocated shoulder)

- The injury does not result from physical contact

with an object or person

• But from internal forces built up by the actions of

the performer, (i.e over-stretching, poor technique)

Overuse injury-when excessive and repetitive force is placed on

the bones and other connective tissues of the body

-symptoms begin when there is a change in training

practices (↑ traning,poor technique and equipment) Onset of

injury

ACUTE CHRONIC

*An acute injury is an injury

that occurred recently as a

result of a traumatic event

*i.e; fractures, dislocations,

ligaments sprain,

contusions, muscle strain

*is the result of

overuse or a long-

standing condition

*i.e: overuse

syndrome,

tendonitis, bursitis

and arthritis

-Total 83 injuries & 64 illnesses were recorded (276 athletes)

-Muscles strains and tears (most common injury),

then ligamentous and soft tissues contusions/bruises

-injury highest among badminton, hockey and rugby

‘Patterns of Injuries and Illnessess among Malaysian athletes at the ASEAN Games 2014’

(Mohamad Shariff et al.Sains Malaysiana. 2016)

-Study period (January 2005 –June 2007), badminton player

-469 musculoskeletal injuries recorded

-majority were overuse injury and involved knee

‘Musculoskeletal injuries among Malaysian

badminton players’

(Shariff et al.Singapore Med J.2009)

-Total 86 injuries were reported (141 matches)

-injuries mostly involved the lower extremity(44%), trunk(14%) and upper limb (13%)

‘Incidence and characteristics of injuries during the 2010 FELDA/FAM National Futsal League in Malaysia’

(Shariff AH, Azril MA et al.PLOS ONE.2014)

1. Anterior Cruciate ligament(ACL)

2. Meniscus injury

3. Patellofemoral pain syndrome

4. Hamstring tear

5. Achilles tendinopathy

6. Shoulder impingement

-ACL is one of four

stabilizing ligaments

-Protects integrity of

menisci and articular

cartilage

-ACL prevents excessive

anterior translation of the

tibia and internal or

external rotation of the

tibia on the femur

Mechanism of Injury:

-Usually a history of non-

contact injury (70%)

-Common in any physical

activity that requires quick

change in direction(pivoting)

or a contact sport

- involves sudden

deceleration,

hyperextension and tibial

torsion

*Signs & Symptoms:

*Acute

-Marked pain and pop

-Significant knee swelling

-Difficulty bearing weight on the affected knee

-unstable feeling knee

*Chronic

-The knee feels loose

-Feeling of “buckling”, “giving way” or instability

-Pain and swelling

-can associated with other injuries to knee structures:

-Ligaments

*Medial Collateral Ligament (MCL)

*Posterior Cruciate Ligament (PCL)

*Posterolateral Corner

-Meniscus-(cushions in the knee)

*Medial

*Lateral

-Articular cartilage (gliding cartilage on the ends of bones)

*Diagnosis:

-History

-Know the mechanism of ACL injuries!

-Appropriate mechanism accompanied by what

athlete describes as a “pop” and excruciating pain

-PE

-Excessive swelling with knee effusion

-Decreased range of motion (ROM)

-inability to contract quadriceps

-Special test (ADT , Lachman’s test, Pivot shift)

-X-rays� usually normal

but should be obtained to

ensure that there is no

fracture

-MRI-excellent for

evaluating not only the

ACL but also the

meniscus, articular

cartilage and other knee

ligaments

*Risk Factors

-Individuals participating in high risk sports

-Playing surface

-High shoe-surface friction that increase performance

(artificial turf)

-Neuromuscular deficits of the female sex

-Females tend to activate their quadriceps near full

knee extension, thus landing with smaller angles of

knee flexion than their male counterpart

-Females show earlier neuromuscular fatigue

*Treatment

-Rest

-Ice

-Elevation

-Compression

-Protected Weight Bearing

-Brace

-Surgery

(arthroscopic ACLR)

*Rehabilitation

-Prerehab (Gold-standard)

*Implemented immediately after diagnosis

*Decrease pain and swelling

*Increase ROM, quad strength, and proprioception >90% of

contralateral leg

*Prerehab allows for quicker post-operative return to ADLs

and physical activity

-Rehab Progression varies depending on graft choice

*Also focuses on decreasing pain and swelling, while

increasing ROM, strength, and proprioception

*Prevention

-ACL injury prevention programs

-Programs focus on modifying neuromuscular and biomechanical risk factors

*Agility drills and plyometric exercises

*Recognition of injury associated actions and positions

*Educate athletes in proper jumping techniques, softer landings, instant recoil, and correct posture and alignment

*Meniscus = ‘little moon’ in greek,

*Absorbs shock, distributes load, stabilizes joint, proprioception, joint lubrication, joint nutrition

*Thick at periphery →thin centrally

*Causes:

-Sudden

twisting/rotation

Esp in young athletes

-Simple movements,

in older knee

(degenerative tears)

*History:

-Clicking, catching or locking

-Feel a “pop”

-Worse with activity

-Tends to be sharp pain at joint line

-Swelling and stiffness

*PE:

-joint line tenderness to palpation

-effusions common

-Positive meniscal tests

-Knee will not reach full extension, flexion

minimally affected (‘locked knee’)

*

*Different types of meniscus tear

*Imaging:

-MRI

*Treatment:

-RICE

-Crutches

-NSAIDs

-Surgical repair or excision (arthroscopic)

-Meniscectomy

-Meniscus repair

*Prognosis:

*Results of surgical repair/excision are very good

*Return to full activities 2-4 months after surgery; tends to be

quicker for athletes

*When to refer:

*Most symptomatic meniscal injuries require surgery

*Retropatellar or

peripatellar pain resulting

from physical or

biomechanical changes in

the patellofemoral joint

*Many forces interact to

keep the patella aligned

*Patella not only moves up

and down, but rotates

and tilts

*Many points of contact

between patella and

femoral structures

*History:

-Vague anterior knee pain with insidious onset

-Common cause of anterior knee pain in women

-Tend to point to front of knee when asked to localize pain

-Worse with certain activities, i.e. ascending or descending hills & stairs,running, jumping or squatting

-Pain with prolonged sitting → ‘Theater sign’

-Popping or crackling sounds when climbing stairs/ standing up after prolonged sitting.

-No meniscal or ligamentous symptoms

Extrinsic risk factors:

-Training errors

*Overuse – Most common

-Equipment

-Change in playing surface

Intrinsic risk factors:

-Misalignment of the legs between the hips and the ankles

-Muscular imbalance/weakness

-Abnormal trochlear groove and shape

*Xray (Merchant’s view)

*Treatment:

-Relative

rest/Modification of

activities

-Icing

-NSAIDS

-Patellar braces

-Addressing foot

problems with foot

wear and orthotics

*Treatment:

-Mainly conservative

-Physical therapy

-Improve flexibility

-Quad strengthening, especially VMO

-Patellar taping

-Surgery

*Strengthening exercise *Patellar taping

- most common type of muscular

strain that effect the lower

limb in the elite athlete

- They are associated with sports

which involve rapid

acceleration or deceleration,

jumping, cutting, pivoting,

turning or kicking

- Often associated with

inadequate warm-up/fatique

History:

-sudden onset of posterior thigh pain during strenuous exercise

-may have audible ‘pop sound’ heard-during acute onset

-feel tightness / ‘pull’ limiting performances /participation

-recurrent hamstring strains dt inadequate treatment & premature RTP

*PE:

-ecchymosis

-may have palpable defect

in severe cases

(athlete lying prone &

knee flexed 90’)

-resisted knee flexion

(weak)

-Passive knee extension

with the hip flexed 90’

*Diagnosis

-Xrays:

-beneficial if

suspected case with

ischial tuberosity avulsion

-Ultrasound,MRI can be

used to evaluate

hamstring injuries

*Treatment:

-Rest (cessation of sports)

-Bagged crushed ice

-Walk using crutches

-Compression reduces

hemorrhage and oedema

-NSAIDS

-Gradual increasing ROM and

strengthening exercises

-SURGERY ONLY (recommended

for proximal injuries with IT

avulsions displaced >2cm)

*

-Thickest,largest and strongest tendon in the body

-Origin from 3 muscles gastrocnemius,soleus and plantaris muscles

-begins near the middle of the calf muscle

-Insertion on calcaneal tuberosity

-Function: walk, jump, run

History:

-Achilles tendinopathy causes pain, swelling, stiffness and

weakness of the Achilles tendon

-caused by repeated tiny injuries (known as microtrauma)

to the Achilles tendon

-the tendon does not heal completely, that over time,

damage to the Achilles tendon builds up and Achilles

tendinopathy can develop.

-Chronic stress to the tendon - tendinopathy

-Failure to adapt to recurrent excessive loads

- Tendon damage result from stresses within physiological

limits, since frequent microtrauma may not allow enough

time for repair

Extrinsic risk factors:

-Training errors

*Overuse – Most common (sudden increase in amount & exercise intensity)

Intrinsic risk factors:

-Structural risk factors

-Overpronation

-Tightness or weakness of soleus, gastrocnemius & Achilles tendon

-Degenerative risk factors

-Bone spurs – againts the tendon & cause pain

*

*PE:

-Chronic soreness and morning stiffness

-Pain with dorsiflexion

-Pain with plantar flexion against resistance

-Mid swelling

*X-ray *Treament:

*Multifactorial approach:

-Rest (complete or modified activity),

-Medication (NSAIDs)

-Orthotic treatment (heel lift, change of shoes)

-Stretching and strength training (i.e Heel raise, gastroc

strecthing)

*Eccentric training

- alters tendon pathology in both the short term and the

long term by

- increasing the tendon volume

-increasing the tensile strength in the tendon over time

*Alfredson's eccentric training programme

- successful in approximately 90% of those with

mid-tendon pain

- in Insertional Achilles tendon pain, the response

rate is approximately 30% of tendons.

*Extracorporeal shock wave therapy

- decreases pain

*Night splint

Autologous blood injections (PRP)*Helps in the healing process

*Surgery

-Surgical treatment for tendons that fail to respond to conservative treatment

-Percutaneous tenotomy resulted in 75% of patients reporting good or excellent results after 18 months

-Proper conditioning and warm-up

-Heel raises is a good warm-up

*Impingement syndrome is characterized by pain in the

shoulder due to inflammation of the tendons of the

rotator cuff or the bursa (subacromial bursa) that sits

between the rotator cuff and the roof of the shoulder

(acromion)

*Acute – trauma

*Chronic – age-related

-The rotator cuff is a

series of four muscles that

surround the ball of the

shoulder (humeral head)

- The subacromial bursa

sits over the top of the

cuff, allowing for the cuff

tendons to slide near the

roof of the shoulder

without undue friction

*Mechanism:

-compression of rotator cuff againts acromion from:

-direct blow on shoulder

-fall on flexed elbow

-repetitive microtraumafatigue

-rotator cuff tendinosis, SA bursitis

-Degenerative irritation of

cuff/bursa by:

-anterolateral SA

osteophyte

-Thickened CA ligament

-Type III acromion

Signs & symptoms

Pain around the shoulder,

at the outer portion of the

upper arm

- Pain that is worse with

shoulder function

(reaching overhead,

lifting)

- Pain at night

-tenderness, swelling,

-Loss of strength

-Limited motion of the shoulder, especially reaching behind (such as to back pocket or to unhook bra) or across body

-Crepitation when moving the arm

-Biceps tendon pain, worse when bending the elbow or lifting

*PE:

-Restricted active and passive

ROM due to pain

-Special test:

-Impingement test

(Neer, Hawkins) test +ve

-painful FF arc (60’-120’)

-GT tender on palpation

-↓ internal rotation

-decreased supraspinatous

strength

*Risk Increases with

- Contact sports such as football, wrestling, and boxing

- Throwing sports, such as baseball, tennis, or volleyball

- Weightlifting and bodybuilding

- Poor physical conditioning (strength and flexibility)

- Inadequate warm-up before practice or play

- spurring of the acromion

Preventive Measures :

• Appropriately warm up and stretch before practice or

competition.

• Allow time for adequate rest and recovery between

practices and competition

• Maintain appropriate conditioning:

-Shoulder flexibility

-Muscle strength and endurance

*X-rays:

-True AP, axillary,caudal tilt

-TRO GH & AC degenerative disease, calcified tendinitis, high

riding humeral head(RC tear)

-Outlet view

-TRO type III acromion, anterolateral acromial osteophyte

*USG of shoulder

-TRO RC tear,subacromial

bursitis

-diagnostic & therapeutic

USG injection

MRI

-SST tendinosis,thickening

SA bursitis

-Osteophytes formation

(AC)

*Treatment

-regular cold therapy

-NSAIDS

-minimize use of arm at

shoulder height

-stop overhead activities

-RC, scapular stabilizers,

strengthening program

-subacromial injection with

steroid & local anaesthetic

*Treatment

Non-operative

->70% respond to

treatment

-consider surgery when

-fail conservative

Operative

-restricted overhead

activities 3-6 weeks

-Subacromial

decompression +

bursectomy +

acromioplasty

*Screening the athletes (PPE) before

participating in major sports events/off

season

*Identify the problem( sports injury) and

manage accordingly

*Implement the injury prevention steps

*Proper rehabilitation and ready for RTP