david g. liddle, md, facp - internal medicine | acp• tenoplasty or tendon repair. vanderbilt...

Vanderbilt Sports Medicine

Common Sports & Overuse Injuries

David G. Liddle, MD, FACPAssistant Professor of Orthopedics & Rehabilitation

Assistant Professor of Internal Medicine

Vanderbilt University Medical Center

Nashville, TN


Disclosures

• No Financial Disclosures

• No Educational Disclosures


Objectives

• Review pertinent anatomy and pathology associated with common sports injuries and MSK conditions

• Review historical and physical exam findings associated with these conditions

• Review imaging findings relevant to these causes of pain and discuss a rationale for appropriate use of diagnostic tests

• Review the best evidence available to the guide treatment of these conditions


Non-Arthritis Shoulder Pain

Non-Operative

• Subacromial Impingement

• Subacromial Bursitis

• Adhesive Capsulitis– “Frozen Shoulder”

• Biceps Tendonitis

Operative &/or Non-Op

• Rotator Cuff Tear– Acute, Known Injury – Surgery

– Chronic, Unknown Injury – Non-Op

• Proximal Biceps Tendon Tear

• Labral Tear

• Glenohumeral or AC Joint Arthritis

• AC Joint Sprain– “Separated Shoulder”

• Shoulder Instability


Proximal Biceps Tendon TearProximal Distal

http://images.ookaboo.com/photo/m/Bicepstendon10_m.jpg

images.rheumatology.org

www.eastbaysportsmed.com


Proximal Biceps Tendon TearHistory

• Pain and/or pop at anterior shoulder but usually not painful after initial event

• May have bruising at anterior shoulder that tracks distally

Exam

• “Popeye Deformity” with defect proximal and bulge distal

• ROM usually normal

• May be Tender To Palpation at site of tear

• Weakness on elbow flexion with hand in supinated position

• Usually normal strength with hand at neutral or pronated


Proximal Biceps Tendon TearImaging

• None required unless history of trauma– If trauma, XR to r/o fracture

– MRI usually does not change management

Treatment

• Reassurance

• Surgery if – Relative strength deficit is

intolerable or affects work/play

– Deformity is cosmetically unacceptable


AC Joint Sprain


AC Joint SprainHistory

• Fall onto/Blow to superolateral shoulder with ADducted arm

• Pain radiates from superior shoulder to lateral neck and upper trapezius

• Pain with reaching, especially across body

• Pain can prohibit pushups, bench press, and overhead lifting

• Aching rest pain

• No change in shoulder pain with Neck ROM

Exam

• Tender To Palpation at AC joint

• May have step off at AC Joint

• Pain with Cross-Arm Adduction test

• Likely won’t have secondary Impingement signs unless they present late


AC Joint SprainImaging

• 3-4 views of the Shoulder

– AP Int. & Ext. Rotation & Axillary +/- Scapular-Y view

– Degree of Separation determines type of dislocation

Treatment• Type I and II – Non-Op

– Sling initially and Ice

– PO NSAIDs or APAP or Narcs (rare)

– AC joint CS Injection

– Rehab

• Avoid developing Impingement

• Type III – Non-Op or Surgery

– If distal clavicle overrides acromion on Cross Arm ADduction test Surgery

• Type IV-VI - Surgery

– AC Joint Reconstruction

www.aafp.org


AC Joint Sprain XRGrade 2 Grade 3

Grade 4 Grade 5


Glenohumeral Instability

http://www.intechopen.com/source/html/40393/media/image6_w.jpg

http://emcow.files.wordpress.com/2012/09/shoulder-disloc1.jpghttp://www.imageinterpretation.co.uk/shoulder.html


Glenohumeral InstabilityHistory

• Subluxation– Popped back in w/o specific Tx

• Dislocation– Someone else reduces or specific

technique used to relocate joint

• Direction of Instability follows humeral head– ABduction-ER = Anterior (90%)

– Abduction = Inferior

– Forward Elevation = Posterior

Exam

• Arm hanging limp at side

• Inability to reach across body

• Inability to externally rotate arm

• Anterior Instability– Apprehension/Relocation tests

• Sensitive & Specific for Fear, Not Pain

• Inferior Instability– Sulcus on Traction tests

• Posterior Instability– Posterior Jerk test


Anterior InstabilityApprehension and Relocation Tests

http://www.chiro.org/LINKS/FULL/Shoulder_Dislocation_in_Young_Athletes.html


Posterior & Inferior Instability

Posterior Jerk Test Sulcus Sign with Traction Test

http://i1.ytimg.com/vi/gPuCikFKUzE/maxresdefault.jpg http://o.quizlet.com/Y8H2wK5Imz4g0bpp.9v3Pw_m.jpg


Glenohumeral InstabilityImaging

• 4 views of the Shoulder– AP Int. & Ext. Rotation &

Axillary & Scapular-Y view

• Axillary view prevents missing a posterior dislocation

• Classification

Treatment

• Reduce Dislocated Joint– Level I – Intra-articular lidocaine is

preferred to IV sedation

• Same success; Less complications (0.9 vs. 16.4%)

Fitch RW, Kuhn JE. Acad Emerg Med 2008

• Sling Immobilization– Level I & II – Ext. Rot. may reduce

recurrence; Req. 3 wks. (1/4 studies)Itoi et al. JBJS 2007

• Sling vs. Surgery (No studies Rehab vs. Sx)

– Level I – Non-Op Tx has higher risk of recurrence (47 vs. 16%)

Kirkley et al. Arthroscopy 1999

Kuhn JE, Dunn WR et al. J Shoulder Elbow Surg. 2011


Lateral Epicondylopathy


Background

• Degenerative process involving the origin of:

– Extensor tendons at the lateral elbow

• Often repetitive, sport or occupation relate


Lateral Epicondylitis Clinical History

• Point tenderness over the lateral epicondyle and extensor complex

• Pain upon gripping or rotation

• Pain with backhand

• Usually recreational player

– Most who get it, don’t play tennis

Kibler, Clinical biomechanics of the elbow in tennis: implications for evaluation and diagnosis, Med and Sci in Sports and Exercise, 2004.


Physical Exam In Lateral Epicondylitis

Lat. epicondyle & extensor mass

Pain with resisted extension

Pain with passive terminal flexion


Imaging


Treatment


Anatomy Review


Regional Approach To Hip PainAnterior

• Hip Arthritis

• Iliopsoas Bursitis

• Hip Flexor Strain

• Osteitis Pubis

• Femoral Neck Stress Fracture

• Femoroacetabular Impingement

• Hip Fracture

• Greater Trochanteric Bursitis

• Hip ABductor Tendonopathy

• Meralgia Paresthetica

• Hamstring Strain

• Ischial Bursitis

• Sacroiliac Joint Dysfunction

• Lumbar Radiculopathy/Sciatica

• Piriformis Syndrome

• Snapping Hip Syndrome

• Hip ADductor Strain

• Apophysitis / Avulsion Fractures

• Pelvic Stress Fractures

• Iliac Crest Contusion

Posterior

Lateral

Depends/Other


XR To OrderIf They Can Walk, They Can Stand!

Standing AP Pelvis, Lateral of the involved Hip

If Fall/Trauma w/ Pelvic Pain

- Add Pelvic Inlet/Outlet Views and

Lateral of Sacrum


Hip Pain Radiating Patterns


Greater Trochanteric Bursitis


Greater Trochanteric BursitisHistory

• Lateral hip pain

• Pain sleeping on affected side or lying on unaffected side without (or relieved by) pillow between knees

• Chronic/insidious onset more likely than acute w/o h/o trauma

• Pain may radiate to lateral thigh but no numbness or paresthesias

Exam

• TTP at greater trochanter

• Weakness in gluteus medius/deep hip rotators

• Weak on affected side with Trendelenburg Stance or Single-Leg Squat tests

– Often present bilateral but asymmetric

• Worse on sympt. side

https://www.youtube.com/watch?v=1iZ09aJ3bpI

https://www.youtube.com/watch?v=v2hX4qry5jY


Greater Trochanteric BursitisImaging

• Standing AP Pelvis and Lateral of affected side– Usually normal but my see

enthesopathy at greater trochanter

Treatment

• PT for hip/core strengthening

• Voltaren gel

• Corticosteroid Injection

• Bursectomy (rare/salvage)


Hip ABductor Tendonopathy


Hip ABductor TendonopathyHistory Exam

• Lateral and/or posterior hip pain

• Posterolateral pain crossing legs

• Pain lateral with IR or ADduction

• Pain sleeping without (or relieved by) pillow between knees

• Chronic/insidious onset most likely

• No radiating symptoms

• TTP at Gluteus medius, esp. at insertion site on posterior greater trochanter

• Pain lateral with passive IR

• Pain with resisted ER and ABduction

• Weakness in gluteus medius/deep hip rotators


– Often present bilateral but asymmetric

• Worse on sympt. side

https://www.youtube.com/watch?v=1iZ09aJ3bpI

https://www.youtube.com/watch?v=v2hX4qry5jY


Hip ABductor TendonopathyImaging

• Standing AP Pelvis and Lateral of affected side– Usually normal but my see

enthesopathy at greater trochanter or tendon insertion

– May show calcific tendonopathy

Treatment

• PT for hip/core strengthening

• Corticosteroid Injection– Ultrasound Guided for tendon

sheath or calcific tendonopathy

• Tenoplasty or Tendon repair


Calcific Hip ABductor Tendonopathy


Hip ABductor CalcificTendonopathy Treatment

• U/S Guided Lavage & CS Injection; Debridement if too large or failed CSI


Muscle Strains


Hip Muscle StrainHistory

• Pain at mid belly, origin, or insertion of muscle

• Usually acute eccentric load or repetitive stress

• Both Acute and Chronic presentations are common

Exam

• TTP at muscle or tendon– Myotendonous Junction common

• Pain with Passive Stretch

• Pain with Resistance

• Examples– Hip Flexor – P-Ext & R-Flex

– Hip Adductor – P-ABd & R-ADd

– Hamstring – P-Flex & R-Ext of Hip as well as P-Ext & R-Flex of Knee


Hip Muscle StrainImaging

• Standing AP Pelvis and Lateral of affected side– Usually Normal but must r/o

avulsion fractures

Treatment

• Rehab– Strengthen > Stretch LOE 1 & 2

– Eccentric > Concentric LOE 1 & 2

– Progressive Agility and Trunk Stabilization > Static Stretch and Strengthen LOE 2

– Proprioceptive Neuromuscular Facilitation Stretching > Conventional Stretching LOE 1


Femoroacetabular DJDHistory

• Anterior, deep pain in the hip that is constant– “Hopeless” pain

• Worse with activity, sitting, or upon standing/start-up

• (+) Rest Pain

• Radiate to groin/medial thigh

• Usually insidious onset– May have h/o trauma or h/o

pain/limp as child

• No change in hip pain with lumbar ROM

Exam

• Limited P/AROM on IR/ER/Flex

• Pain with passive Int/Ext Rot.

• Reproduce pain with log roll

• No pain with Straight-Leg Raise


Log Roll TestIntraarticular Pathology


• Standing AP Pelvis and Lateral of affected side– Joint space narrowing,

osteophytes, and acetabular rim and/or femoral head and/or femoral head flattening

Femoroacetabular DJD

• Imaging


Non-Operative

• Physical Therapy

• Weight Loss– Hip carries 3-8x Body Weight

• Pain Medicine– NSAIDs

– Tylenol (APAP)

– Narcotics

• U/S Guided Steroid Injections

• Viscosupplementation– Level I – Not Clinically Significant

Migliore A, Arthritis Res Ther. 2009;11(6)

Richette P, Arthritis Rheum. 2009 Mar;60(3)

Operative

• Non-Joint Replacement

• Total Joint Replacement

Femoroacetabular DJD


Anatomy Review


Surface Anatomy

Medial Lateral


XR To OrderIf They Can Walk, They Can Stand!

Bilateral Standing AP, Bilateral Sunrise, and Lateral


Differential Diagnosis For Knee Effusions

• Injury/Event

– Fracture

– Dislocation

– Cruciate Tear

– Bone Bruise

– Meniscus Tear

• No Injury/Event

– DJD

– Septic Arthritis

– Gout/CPPD

– PVNS

– Chondromatosis

– Inflammatory Arthritis

– Reactive Arthritis

– Spontaneous Hemarthrosis


Knee Effusions• Leg MUST Be Straight

– If not, fluid will hide in Popliteal Fossa

• Direct Palpation– Feel femoral condyles at the patella

– Compress suprapatellar pouch

– Feel for fluid femoral at the condyles

• Visualize Fluid Wave

– Milk Fluid from the anterior-medial joint line

– Push fluid out of superolateral suprapatellar pouch

– Watch for wave at anterior-medial knee


Medial Collateral Ligament Sprain


Medial Collateral Ligament SprainHistory

• Pain at medial knee

• Relieved by resting leg on lateral foot with ER hip

• Usually with lateral blow to knee or fall with knee falling into valgus

Exam

• TTP at MCL on medial joint line and/or above or below joint line

• Graded based on degree of laxity on valgus stress– Grade 1 – Pain but No Laxity

– Grade 2 – Pain and Laxity at 20° flexion

– Grade 3 – Laxity in Full Extension +/- Pain


Medial Collateral Ligament SprainImaging

• Bilateral Standing AP, Bilateral Sunrise and Lateral of affected side

• Findings = Normal– r/o fracture, esp. in skeletally

immature

Treatment

• Initial Therapy– Straight leg raises and full range

of motion

– Double-hinged knee brace

• Not Knee Immobilizer

• PT for hip/core/quad rehab

• Return To Play– Full Strength, ROM, & Speed for

all things activity requires

• Grade 1 – 2-4 weeks

• Grade 2 – 4-6 weeks

• Grade 3 – 6-8 weeks; ? Surgery


Medial Meniscus Tear


Medial Meniscus TearHistory

• Pain at affected joint line

• Worse with incr. activity, sitting, or upon standing/start-up

• May have catch/release/locking symptoms

• Usually starts with weight bearing + twist injury

• May result from both an event or a process

Exam

• TTP at posterior medial (NOT anterior medial) joint line

• Consider Duck Walk test if Hx convincing but exam equivocal

• McMurry’s is only 50-60% sensitive and specific

• May or May Not have an Effusion


Medial Meniscus Tear vs. MCL Sprain• MCL Divides Medial

Joint Line Into Ant/Post

– MCL Pain tracks Vertical or Perpendicular joint line

– MMT Pain tracks Horizontal or Parallel to joint line

• ≥ 95% of MMT are in the POSTERIOR Horn


Medial Meniscal TearImaging

• Bilateral Standing AP, Bilateral Sunrise and Lateral of affected side– r/o or determine severity of DJD

• Consider MRI if joint line tenderness AND <50% joint space narrowing on XR– Don’t Create an MRI Bomb!

Treatment

• PT for hip/core/quad strengthening and quad/hamstring flexibility,

• CS Injection

• Arthroscopy– If >50% medial joint space

narrowing, MMT Tx changes from:

• Non-Op

– 75% symptom relief 50%

• Surgery

– 90% symptom relief 70%


Meniscus Tears Therapy

• Evidence – Level 1

– Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis. Khan et. al. CMAJ. 2014 Aug 25

• Conclusion – There is moderate evidence to suggest that there is no benefit to arthroscopic meniscal debridement for degenerative meniscal tears in comparison with nonoperative or sham treatments in middle-aged patients with mild or no concomitant osteoarthritis. A trial of nonoperative management should be the firstline treatment for such patients.


XR ReviewMeniscus Tears and Arthritis

• Favors Non-Op– ≥ 50% JSN

– No Injury

– Less Active

– No Mechanical Symptoms

• Favors Surgery– <50 % JSN

– Injury/Event

– Active &/or Young

– Mechanical Symptoms

Clinical Meaningful Difference>50% Joint Space Narrowing (JSN) = Changes

Arthroscopic outcomes & favors rehab as initial Tx


Iliotibial Band Friction Syndrome


Iliotibial Band Friction SyndromeHistory

• Pain at lateral knee

• Worse with incr. activity, sitting, or upon standing/start-up

• Worst in mid-range of motion

• Prefer to walk down stairs/hills with peg/straight leg

• May radiate to lateral leg or distal/lateral thigh

• Common in runners

Exam• TTP at lateral femoral condyle or

Gurdy’s tubercle

• Weak Hips/Core



Iliotibial Band Friction SyndromeImaging

• Bilateral Standing AP, Bilateral Sunrise and Lateral of affected side

• Findings = Normal

Treatment

• PT for hip/core strengthening and IT band stretching

• Foam Rolling

• CS Injection at IT Band and Lateral Femoral Condyle Bursa


Ankle Sprains

https://www.gothamfootcare.com/services/ankle-sprain

https://heidenortho.com/types-ankle-sprains/


Which Ligaments Involved?

Vanderbilt Bone and Joint


Anatomy

• Lateral Joint Stabilizers

– Anterior Talofibular Ligament (ATFL)

– Calcaneofibular Ligament (CFL)

– Posterior Talofibular Ligament (PTFL)

• Medial Joint Stabilizers

– Superficial and Deep Deltoid Ligaments

• Bone Stabilizers

– Anterior Tibiofibular Ligament (AITFL)

– Posterior Tibiofibular Ligament (PITFL) with deep portion

– Interosseous Ligament



Anatomy – Syndesmosis• Contributions

– AITFL: 35%

– IOL: 22%

– PITFL: 40%

– IOM: <10%

• Primary Resistors to External Rotation and Lateral Talar Shift

– Medial malleolus

– Deltoid LigamentBorrowed from Dr. Michael Khazzam



Case

• 21 yo injures his ankle

– Swollen

– Unable to bear weight



Case – Exam

• TTP lateral malleolus tip and anterior tib/fib area

• NT over proximal fibula

• Negative Squeeze test

• Positive ER test

• Anterior Drawer and Talar Tilt unable to assess



Ottawa Ankle Rules

• Pooled Analysis

– 97.6% sensitive

– 31.5% specific

– 0.08 Neg LR

Bachmann BMJ 2003;326:1 Level II



Ankle Instability Tests

• Anterior Drawer

• Optimum position

– 90o knee flexion

– 10o ankle plantarflexion

• No one measurement is diagnostic, more important side to side

Lynch J Athl Train 2002;37(4):406Kovaleski J Athl Train 2008;43(3) and Croy et al. J

Orthop Sports Phys Ther 2013;43(12).




• Anterolateral Drawer

– Pivots around Deltoid

– 100% sens/spec compared with 75%/50% with Anterior Drawer

Lynch J Athl Train 2002;37(4):406Phisitkul Foot Ankl Int 2009;30(7):690. Cadaver study




• Talar Tilt

– Neutral and plantar position

– Inversion force

Lynch J Athl Train 2002;37(4):406



What about the Syndesmosis?• MRI proven injuries

– Sensitive tests• Single leg hop: 89%

• Tenderness: 92%

• Dorsiflexion/ER test: 71%

– Specific tests• Pain out of proportion:

79%

• Squeeze test: 88%

Sman et al. BJSM epub 11/19/2013.


Lynch J Athl Train 2002;37(4):406


So we have an ankle sprain…

• AAOS guidelines

– Rest

– Ice

– Compression

– Elevation

– NSAID’s



How about Functional immediately?• Compared walking boot to

functional

• Acute presentation

– MRI proven tears

• Functional

– Better AOFAS scores

– Back to work quicker

• Pain and instability equal

Prado et al. Foot Ankle Int, epub 2014.



Time to Move – PT• Focus on strength,

neuromuscular control

• Grade I and II sprains

– Accelerated (1st week) better outcomes than waiting a week

• 8 week home proprioceptive

– 11% AR reduction in re-injury

– NNT = 9

Bleakley BMJ 2010;340:c1964 (Level I), Hupperets BMJ 2009;339:b2684 (Level 1), and image from

Sports Health 2010;2(6):460.



Ankle Braces• Effective

– Taping = Braces

– Braces cheaper

– 15-50% reduction in ankle sprains

– Prevents recurrences

• Should be coupled with neuromuscular training

• Reduce incidence but not severity

Verhagen et al BJSM 2010;44 and Janssen et al. BJSM 2014, epub



Plantar Fasciitis


Plantar Fascia Anatomy

• Originates at the anteriomedial aspect of the calcaneus

• Spreads broadly as it extends distally to divide into 5 digital bands at the MTP joints

• Inserts into the base of the proximal phalanx of each toe


Mechanics

• Relatively inelastic structure– Maximal elongation is 4%.

• “Windlass effect”– High tensile forces concentrated at

the calcaneal origin during the toe-off phase

• Raises the arch of the foot during the push-off phase of walking

• Gastrocnemius-soleus muscles – Contract in the toe-off phase while

the body weight is on the forefoot and the PF is under tension

http://charlieweingroff.com/wp-content/uploads/Windlass.png


Mechanics

• “Bow and bowstring”


Mechanics

• Walking Heel Strike = 110% body weight

• Running Heel Strike Force = 200% body weight


Calcaneal Exostoses

• DuVries HL, Arch Surg, 1957– The concept of physical impingement into the plantar fat pad was

promoted

• Williams PL, et al, Foot Ankle, 1987– 75% of patients with heel pain had heel spurs

• Asymptomatic patients had a 63% incidence of heel spurs

• Davies MS, et al, Foot Ankle Int, 1999– 50% of patients with heel pain had heel spurs


Runners and PF

• Up to 10% of runners affectedD’maio, Sports Med and Rehab Series, 1993

• Novices especially at risk

• Threshold of 40miles/wkFredericson and Misra, Sports Med, 2009

• Long distance runners comprise a higher percentage than the population at large of those undergoing surgery for PFRiddle DL, et al, JBJS, 2003


Riddle DL, et al, JBJS, 2003Variable Odds ratio 95%

Confidence Interval

Ankle dorsiflexion ≤0°

23.3 (compared with individuals who had >10° of dorsiflexion)

4.3-124.4

BMI ≥ 30 kg/m2 5.6 (compared with individuals who had a BMI of ≤25 kg/m2)

1.9-16.6

Majority of time spent on feet during workday

3.6 (compared with individuals who did not spend time on their feet)

1.3-10.1

Recreational Runner 2.8 (compared to non-runners)

0.4-22.7


Clinical Diagnosis

• Gradual onset of pain in the inferior heel

– Usually worse with the first step in the morning or after a period of inactivity

• Pain lessens with gradual increase in activity but may worsen toward the end of the day with increased duration of weight-bearing

• Associated paresthesias uncommon


Clinical Diagnosis

• History of increased intensity and/or mileage

• Change in footwear or surface

• Other risk factors present

– Standing Occupation

– Obesity

– Pes Planus

• Pain can be bilateral

– Approximately 1/3 of cases


Clinical Diagnosis

• Inspect stance/gait

– Pes planus, pes cavus

• Maximal tenderness over the anteromedial aspect of the inferior heel or midfoot

• Decreased ankle dorsiflexion due to Achilles tightness

– Passive dorsiflexion of ankle and MTPs may exacerbate symptoms

• Windlass mechanism


DDx – Plantar Heel PainSite Diagnoses

Bone Calcaneal stress fracture- positive squeeze test; x-ray may show sclerosis

Bone bruise- Hx of trauma, generalized pain over inferior heel

InfectionCancer

- deep bone pain, nocturnalPaget’s disease

Soft tissue Fat-pad atrophy- elderly, usually no morning pain, atrophy evident

Bursitis

Nerve (entrapment or compression)

Tarsal tunnel syndrome (posterior tibial nerve)First branch of the lateral plantar nerveS1 radiculopathyNerve to abductor digiti quintiNeuropathic pain


Treatment – Plantar Fasciitis

• Nonsurgical:

– NSAIDs

– Injections LOE 2

– Orthoses LOE 2

– Heel Pads

– Physical therapy LOE 2

– Night splints

– Walking casts

– Extracorporeal shock wave therapy (ESWT) LOE 1/2

• Surgical Treatment

– Plantar fascia release


Footwear/Orthoses

• Orthoses may be helpful for runners with excessive pronation, leg length discrepancy, patellofemoral pain, plantar fasciitis, Achilles’ tendinitis, and shin splints

Powerstep

Superfeet


Prospective Cohort – LOE II


Summary

• Conservative therapy should always be the first line of treatment

– More than 90% of cases respond to this approach by 1 year

– Plantar Fascia Stretching & PT, Orthotics, CS Injection supported by level I & II EBM

• Reserve ESWT for recalcitrant cases

– NOT for initial therapy

• Surgical treatment should not be utilized until all conservative measures are exhausted


Questions or Comments


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david g. liddle, md, facp - internal medicine | acp• tenoplasty or tendon repair. vanderbilt...

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