ACL Injuries - Indiana Osteopathic Association

Indiana Osteopathic Association
32nd Annual Winter Update
December 6,2013
Sports Injuries-Outline
 Overview
• Types of injuries
• Prevention
• Specific injuries
 In the United States, about 30 million children and teens
participate in some form of organized sports, and about 3.5
million injuries occur each year.
 Participation in high school athletics is increasing, with
more than 7.3 million high school students participating
annually *
 High school athletes account for an estimated 2 million
injuries and 500,000 doctor visits and 30,000
hospitalizations each year.** *(Source: National Federation of State High School
**JS Powell, KD Barber Foss, 1999. Injury patterns
in selected high school sports: a review of the 19951997 seasons. J Athl Train. 34: 277-84.
Most sports and recreational
injuries are the results of: sprains
(ligamentous injuries), strains
(musculotendinous injuries),and
contusions. Knee injuries (meniscal
& ACL), bursitis, fractures, and
dislocations are all commonly seen.
Top 15 Sports/Recreational Injuries*
 Basketball: 512,213
 Swimming/Diving: 82,354
 Bicycling: 485,669
 Horseback riding: 73,576
 Football: 418,260
 Weightlifting: 65,716
 Soccer: 174,686
 Volleyball: 52,091
 Baseball: 155,898
 Golf: 47,360
 Skateboards: 112,544
 Roller skating: 35,003
 Trampolines: 108,029
 Wrestling: 33,734
 Softball: 106,884
*Treated in ER based on data from the
US Consumer Produce Safety
Commission on Injuries
Acute vs. Overuse Injuries
 Acute - sudden trauma causing sprains, strains,
bruises & fractures
 Overuse - series of repeated small injuries resulting
in pain
Causes of Overuse Injuries
Increasing activity too quickly
Running or jumping on hard surfaces
Training vigorously without adequate rest
Poorly functioning equipment
Improper techniques
Working through pain
Lack of stretching/strengthening
When to See the Physician
 Decreased ability to play
 Inability to play
 Limp, loss of motion or swelling
 Visible deformity
 Severe pain
Injury Classifications
 Sprains: injuries to ligaments
 Strains: injuries to muscles, tendons or the
junction between the two
 Contusions: common bruises or contusions are
the most frequent sports injury.
 Fractures & Dislocations: fractures and
dislocations represent two categories of injuries
involving either bones or joints of the body
Preventing Sports Injuries
 Know and abide by rules
 Wear appropriate protective gear
 Know how to use equipment
 Never “play through pain”
Preventing Sports Injuries
 Skilled sport
specific instruction
 Year round
Preventing Sports Injuries
Make Sure Your Athletes
Always Warm Up First!
Preventing Sports Injuries
 Break a sweat
 Marching
 Walk in place
 Jumping jacks
 Mimic the sport you
are about to do
 Breathe slowly and
Relax into the stretch
Should not feel pain
Avoid bouncing
Hold stretch 30
Stretch both sides
Strains &
 Overstretching of a muscle
Caused by overexertion or by lifting
Frequent site is the Back
Signs & Symptoms
 Localized swelling
 Cramping
 Inflammation
 Loss of function
 Pain
 General weakness
 Discoloration
 Proper warm-up
 Stretch
 Proper mechanics
 Proper cool-down/
 Proper nutrition &
 First aid treatment
 Rest the muscle affected while providing support
 Cold applications initially to reduce swelling
 Warm wet applications applied later because warmth
relaxes the muscles
 Obtain medical help for severe strains and back injuries
that don’t improve
 Injury to the tissues surrounding a joint
Usually occurs when part is forced beyond its normal
range of motion
 Ligaments, tendons and other issues are stretched or
 Common sites for sprains are the ankles and
 Signs and symptoms
Swelling, pain and discoloration
 Impaired motion at times
 First aid for sprain
 Rest and limited or no movement of the affected part
 Ice to reduce swelling and pain
 Compression with elastic bandage to control swelling
 Elevation of the affected part
Obtain medical help if swelling is severe or if there is any
question of a fracture
 Bruise
 Sudden traumatic blow
to body (severe
compression force)
 Usually injury to blood
vessels under skin
 Speed of healing
depends on tissue
damage and internal
 Hematoma formation is
caused by a pooling of
blood and fluid in a
Tendon Injuries
 Tears commonly at
muscle belly,
junction, or bony
 Tendonitis:
inflammation of tendonmuscle attachments,
tendons, or both
 Signs & Symptoms
Pain & inflammation
Worse with movement
 Treatment
NSAIDs-Advil, Aleve
Ultrasound therapy
 Prevention
Slowly increase intensity
& type of exercise
Don’t try to do more
than ready for
Proper warm-up &
Skeletal Injuries
 Occurs when bone
displaces and partially
 Excessive force that
causes the ends of the
bone to separate and
usually remain apart
requiring them to be
put back together
Fracture is a break or loss of structural continuity in
a bone
Wrist/Forearm Fractures
Why are Injuries on the Rise?
• Increase youth participation
• Immature bones and muscles
• Insufficient rest after an injury
• Poor training or conditioning
• Specialization in just one sport
• Year-round participation
Children & Sports
Youths of same age can differ tremendously
in size and physical maturity.
Injuries in Female Athletes
Injuries in Female Athletes
 Common injuries in women/girls include:
 Anterior cruciate ligament (ACL) injuries
 Patellofemoral pain syndrome
 Stress fractures
 Girls Soccer – 1 torn ACL for every 6,500 times a
girl competes or practices
 Boys Football – 1 torn ACL for every 9,800 times
a guy competes or practices
 Girls Basketball – 1 torn ACL for every 11,000
times a girl competes or practices
ACL Injury
 Direct blow to knee
 Non-contact injury,
with foot plant
 Landing on straight leg
 Making abrupt stops
ACL Injuries
 400,000
reconstructions per
year in the US
 Females 4 times more
likely to tear ACL with
non-contact injury
 Women have an increased predisposition to
ACL injury
 Many theories, but no one proven definitive
ACL Injuries
 Intrinsic factors:
 Joint laxity
 Hormones
 Limb alignment
 Ligament size
 Intercondylar
notch size
 Extrinsic factors:
 Conditioning
 Experience
 Skill
 Strength
 Muscle
 Landing
Female athletes rely more on their quads and calf muscle
than their hamstrings
Jumping & landing techniques in women are also different
ACL- What to do?
Learn how to fall, jump and to cut
Plyometric training
Reduce landing forces and improve strength ratios
Increase hamstring activation
Hip Pain in Runner
 18 year old female runner
with 1 month of anterior
groin/inguinal pain
 Pain worse with weight
 Over past week she has
developed night pain
 What are the possibilities?
Differential Dx.
 Torn adductor muscle
 Avulsion of adductor
or sartorius muscle
Pubic ramus fracture
Femoral neck fracture
Femoral shaft fracture
SI joint subluxation
Ruptured iliopsoas
Physical Exam
 Swelling noted in
groin and high
proximal femur
 Pain with all attempts
at motion, especially
internal rotation
 Distal pulses 2+
 No distal sensory
Do You Need X-rays?
AP Hip X-ray
Femoral Neck Stress Fracture
 Groin pain in runner or
jumper- don’t ignore
 Female triad at increased risk
as well as those with an
increase in training and
postmenopausal women
 Need to know which side the
stress fracture is on
(compression vs tension side)
 Plain films often negative
 If stress fracture by x-ray
or further imaging
Compression side
12 weeks to heal +/- NWB
Tension side
Ortho consult/surgery
 Femoral neck fracture-
 Cross train
 Proper nutrition and
Complications if Missed
 Stress to complete
 Avascular necrosis
 Chronic pain
 End of career
Patellofemoral Pain Syndrome
 Anterior knee pain
 Probably more than one etiology
 Chondromalacia (softening of cartilage)
 Malalignment of patella
Patellofemoral Pain Syndrome
Patellofemoral Pain Syndrome
Clinical Features and Exam:
Reports of anterior knee pain
Pain with climbing stairs and/or sitting for prolonged
periods of time
Pressure on the kneecap during bending and straightening
of the knee may elicit cracking and popping with discomfort
Abnormal kneecap alignment
 Acquired
Patellofemoral Pain Syndrome
 Other causes
 Muscle imbalances
 Foot type (either flat or high arched feet)
 Shoes
 Overuse
 Treatment includes: decreasing activity, correct
alignment issues, physical therapy for strengthening,
bracing or
Patellar Dislocation
 Planted foot with
twisting of the body
around the knee (similar
to ACL)
 Kneecap off to the side
 Very painful
Patellar Dislocation
Patellar Dislocation
 Loose Body –
 Brace?
 Rehab
 Return to play when
Osgood-Schlatter Disease
 Jumping sports-
basketball, volleyball
 Dull, aching pain
below the knee
 Bump may be present
 Boys 10-16
 Girls 9-13
Osgood-Schlatter Disease
 Overuse injury
 Traction apophysitis
(growth plate)
Osgood-Schlatter Disease
 Overuse injury
 Traction apophysitis
(growth plate)
Osgood-Schlatter Treatment
 Ice
 Brace
 Relative rest
 Full rest
 Physical therapy
 Knee immobilizer
 Cast
Osgood-Schlatter Disease
 Pain usually goes
away after the growth
plate closes
 The bump will remain
Meniscus Tear
 History of twisting injury to the knee
 Pain
 Giving way
 Locking
 Clicking
 Swelling
Meniscus Tear
 Commonly injured
 “Torn cartilage”
 Two C shaped
cushions between the
thigh and shin bone
 Helps knee joint carry
weight, glide, and turn
Stress Fracture
 Small incomplete break
in bone due to:
Poor muscle balance
Lack of flexibility
Weakness in soft tissue
Biomechanical problems
 Stresses on body are
greater than body can
 Symptoms
 Pain
 Tenderness after activity
 No or little pain in AM,
but pain returns after
Stress Fractures
 Chronic, overuse injury
 Most common in weight bearing bones
Feet, tibia, femoral neck
 Seen commonly in Female Athlete Triad (eating
disorders, amenorrhea (lack of menstrual
periods) & osteoporosis(low bone mass)
 Diagnosis by x-ray, bone scan or MRI
 Treatment is rest, address biomechanical issues--some fxs are surgical (e.g. femoral neck)
Return to Running
 Progression of functional activity
 Very structured, all timed
 Pain & symptoms are to guide progression
 Can have frequent setbacks
Return to Running
 Phase I: Walking
30 minutes, aggressive, pain free
 Phase II: Plyometric Routine
Hopping, 470 foot contacts
 Phase III: Walk/Jog progression
5 minute/1 minute to 2 minute/4minute
 Phase IV: Timed Running Schedule
Intermediate & Advanced
Achilles Tendon Rupture
 History
 Acute pain in the back of the ankle with contraction, no
antecedent history of calf or heal pain
 Average age 35
 Steroids, fluorquinolones, and chronic overuse may
predispose to rupture
 Pathology
 Rupture occurs 3-4 cm above the Achilles insertion in a
watershed area
Achilles Tendon Rupture
 Physical Exam
 Tenderness over achilles
 Palpable defect
 Positive Thompson’s test
 Needle test- needle inserted
midline 10cm proximal to the
superior aspect of the
calcaneous moves towards the
foot when the calf is squeezed
 No evidence to support routine
use of MRI, U/S, or Xray
Achilles Tendon Ruptures
Surgical repair
– Younger active patients
Nonoperative treatment
– Older sedentary patients
– Patients with increased risk of soft tissue
Vascular disease
BMI > 30
Achilles Tendon Ruptures
Nonoperative treatment
– Weaker tendon
– Higher risk re-rupture
– Slower return to sport
– No surgical morbidity
– Lower cost
Indications of Non-Operative
Versus Operative Treatment
 Indications:
 Non-Operative Tx may be indicated for older patients with
minimally displaced ruptures
 Non-Operative may be indicated for patients who are at an
increased operative risk due to age or medical problems
 Note that younger patients w/ expectations of participating in
sports such as basketball may not be good candidates for non
operative Tx
Management of Non-Operative Tx
 Short leg cast strategy (SLC)
SLC is applied w/ ankle in plantarflexion
 Cast is brought out of equinus over 8-10 weeks
 Walking is allowed (in the cast) at 4-6 weeks
 Alternatively, consider using functional brace
starting in 45 degrees of flexion
 Following casting, a 2 cm heel lift is worn for an
additional 2-4 months
 Long leg cast (LLC)
 Initial LLC in gravity equinus for 6 weeks, followed
by short leg cast for 4 weeks
Achilles Tendon Rupture
 Non-Operative
 Resistance exercises started at 8 weeks
 Return to sports in 4 – 6 months
 May take 12 months to regain maximal plantarflexion power
Clinical Evidence to Support
Nonoperative Treatment
 Benefits: no wound complications, no scar, decreased patient cost.
 Disadvantage: up to 39% re-rupture rate, increased patient
dissatisfaction, decreased power, strength and endurance.
 Nistor and later Gilles and Chalmers- non-operative treatment
preferred because:
No hospitalizations
No wound complications
No difference in functional strength
 Gillies and Chalmers
80% vs. 84.3% return of strength compared to unaffected side, non-op and
operative, respectively
 Wills, 775 patients the overall complication rate of surgically
treated Achilles tendon ruptures was 20%.
skin necrosis, wound infection, sural neuromas, adhesions of the scar to the
skin, and the usual anesthesia risks
Achilles Tendon Ruptures
Surgical repair
– Superior tendon strength
– Lower risk re-rupture (1-3%)
– Quicker return to sport
– Surgical morbidity
Superficial nerve injury
– Increased cost
Achilles Tendon Rupture
 Surgical treatment
 Preferred for athletes
 Medial incision avoids
the sural nerve
 Percutaneous vs. Open
treatments described
 Isolate the paratenon as
a separate layer
 The current preferred treatment in young and other
wise healthy patients is surgical repair
 Conservative treatment remains an acceptable
alternative in older, sick or sedentary patients who
have fewer physical demands with limited functional
and athletic goals
Lisfranc Injury
 Lisfranc injuries may
represent 1% of all
orthopedic trauma, but
20% are missed on initial
 Inability to WB, mid-foot
pain, weight bearing xrays are key
Do You Need X-rays?
 Bulky Jones dressing
or posterior splint
 NWB on crutches
 Frequent
neurovascular checks
 Refer to Ortho
Complications if Missed
 Chronic pain
 Arthritis
 Inability to run or
 Acute compartment
 Bursitis
 Shoulder injuries
 Auricular hematomas
 Knee
 Elbow
Shoulder Injuries
 Dislocation
 Separation
Shoulder Dislocation
AC Separation
Surgical Repair
 Shoulder dislocation
 AC joint repair
Ear Injury
Irritation of the ears can occur to the point that
permanent deformity can ensue. Some of these
injuries may include:
 Cauliflower-ear
 Lacerations
 Ruptured
 To avoid these problems, special ear guards should
be routinely worn.
Auricular Hematoma
 Cauliflower ear
 Wrestling
 1.7-23.4% of all injuries
 Direct trauma or abrasion
Head or knee
Incidence reduced with headgear 16% (51% to 35%)
Only 5% of coaches require headgear at practice
Mouth Guards
addition to protecting the teeth, mouth guard
absorbs shock and helps to prevent concussions.
Mouth Guards
Correctly fitted mouth guard prevents the majority of
dental trauma.
should be:
Be comfortable
Unrestricted breathing
Should not impede speech during competition.
is best when retained on the upper jaw and
projects backward only as far as the last molar.
Composed of a flexible, resilient material.
Journal of Pediatrics 10/21/12
Academy of Pediatrics Position Paper
37,000 ER visits
last year
Availability of
Better coaching
Ankle Sprain
 Ligament injury
 Ankle pain, tenderness, swelling
Ankle Sprain
 R.I.C.E. – Rest, Ice, Compression and
 Modify athletic activity
 Rehabilitation ROM, strengthening, flexibility,
 Cooperation and communication
between patient, parents, coaches
and physician
Wrist Injuries
Ganglion Cysts
Mallet Finger
Finger Dislocations
A dislocation occurs when
the normally opposed
bones of a joint are
separated so that the joint
congruity is lost.
Jammed Finger
 Diagnosis only by
 R/O fracture, tendon
 Jamming force on
extended PIP joint.
 Diffuse swelling with
painful movement.
 Exact pathology is not
Jammed Finger
 Bruising of the articular
 Prolong morbidity.
surfaces, secondary
effusion and resultant
edematous soft tissue
swelling most likely
sequence of events.
 Up to 9 months of
 Permanent residual
thickening about the
Plantar Fasciitis
 Painful heel
 “Heel Spur”
 Microtears of plantar fascia
Plantar Fasciitis
 Heel cups
 Tape heel, arch
 Orthotics
Plantar Fasciitis
Stretch (calf and plantar fascia)
Against wall or curb
 On a step
 Plantar fascia stretch
Plantar Fasciitis
 Massage may be helpful
 Warm up well before stretching
 Ice heel, 20-30 minutes
 Anti-inflammatories
 Night splint
Plantar Fasciitis
 Wear good, supporting shoes
 Arch support
 Avoid activities that cause heel pain
 See your physician if pain persists
Shoulder Overuse Injuries
 Tendonitis
 Overhand sports-
pitching, serving:
 Weight lifting
 Use proper technique,
good supervision
Overuse Injuries
 Reduce Intensity
 Warm up before
 Ice afterwards
 Work with coaches
10% Rule
Don’t Increase Activity
by More Than 10% Per Week
 Year round conditioning
 Cross train
 Warm up/ stretch
 Use proper equipment
 Listen to your body
 Seek medical care if pain continues
Thank you

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