ACL Injuries - Indiana Osteopathic Association

Report
SPORTS INJURIES
Indiana Osteopathic Association
32nd Annual Winter Update
December 6,2013
DAVID C. KORONKIEWICZ, D.O.
IU GOSHEN ORTHOPEDICS & SPORTS
MEDICINE
Sports Injuries-Outline
 Overview
• Types of injuries
• Prevention
• Specific injuries
Statistics
 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
Associations)
**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.
Injuries
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
conditioning
Preventing Sports Injuries
Make Sure Your Athletes
Always Warm Up First!
Preventing Sports Injuries
WARM UP
 Break a sweat
 Marching
 Walk in place
 Jumping jacks
 Mimic the sport you
are about to do
Stretching
Stretching:
 Breathe slowly and





deeply
Relax into the stretch
Should not feel pain
Avoid bouncing
Hold stretch 30
seconds
Stretch both sides
Injuries
MOST
COMMON
Strains &
Sprains
THIS
NOT THAT
Strain
Strain
 Overstretching of a muscle


Caused by overexertion or by lifting
Frequent site is the Back
Strains
Signs & Symptoms
 Localized swelling
 Cramping
 Inflammation
 Loss of function
 Pain
 General weakness
 Discoloration
Prevention
 Proper warm-up
 Stretch
 Proper mechanics
 Proper cool-down/
stretch
 Proper nutrition &
hydration
Strain
 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
Sprain
Sprain
 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
torn

 Common sites for sprains are the ankles and
wrists
 Signs and symptoms
Swelling, pain and discoloration
 Impaired motion at times

Sprain
 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
Contusion
 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
bleeding
 Hematoma formation is
caused by a pooling of
blood and fluid in a
tissue
Tendon Injuries
 Tears commonly at
muscle belly,
musculotendinous
junction, or bony
attachment
 Tendonitis:
inflammation of tendonmuscle attachments,
tendons, or both
Tendonitis
 Signs & Symptoms


Pain & inflammation
Worse with movement
 Treatment




RICE
NSAIDs-Advil, Aleve
Ultrasound therapy
Rehabilitation
 Prevention



Slowly increase intensity
& type of exercise
Don’t try to do more
than ready for
Proper warm-up &
stretch
Skeletal Injuries
Subluxation
 Occurs when bone
displaces and partially
separates
Dislocation
 Excessive force that
causes the ends of the
bone to separate and
usually remain apart
requiring them to be
put back together
Fracture
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
ACL
 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
ACL Injuries
 400,000
reconstructions per
year in the US
 Females 4 times more
likely to tear ACL with
non-contact injury
ACL
 Women have an increased predisposition to
ACL injury
 Many theories, but no one proven definitive
cause
ACL Injuries
 Intrinsic factors:
 Joint laxity
 Hormones
 Limb alignment
 Ligament size
 Intercondylar
notch size
 Extrinsic factors:
 Conditioning
 Experience
 Skill
 Strength
 Muscle
recruitment
patterns
 Landing
techniques
ACL


Female athletes rely more on their quads and calf muscle
than their hamstrings
Jumping & landing techniques in women are also different
MRI
 ACL
Normal
Torn-ACL
ACL- What to do?
Prevention


Learn how to fall, jump and to cut
Plyometric training


Reduce landing forces and improve strength ratios
(quadriceps:hamstrings)
Increase hamstring activation
Hip Pain in Runner
 18 year old female runner
with 1 month of anterior
groin/inguinal pain
 Pain worse with weight
bearing
 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
bursa
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
deficits
Do You Need X-rays?
AP Hip X-ray
MRI
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

Get MRI
Treatment
 If stress fracture by x-ray
or further imaging

Compression side


12 weeks to heal +/- NWB
Tension side

Ortho consult/surgery
 Femoral neck fracture-
surgery
 Cross train
 Proper nutrition and
calories
Complications if Missed
 Stress to complete
fracture
 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
Genetic
 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
taping
Patellar Dislocation
 Planted foot with
twisting of the body
around the knee (similar
to ACL)
 Kneecap off to the side
 Very painful
Patellar Dislocation
 MRI
Patellar Dislocation
 Loose Body –
Arthroscopy
 Brace?
 Rehab
 Return to play when
comfortable
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
 NSAIDS
 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
Symptoms
 Pain
 Giving way
 Locking
 Clicking
 Swelling
Meniscus Tear
 Commonly injured
 “Torn cartilage”
Meniscus
 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:






Overuse
Poor muscle balance
Lack of flexibility
Weakness in soft tissue
Biomechanical problems
Malnutrition
 Stresses on body are
greater than body can
compensate
 Symptoms
 Pain
 Tenderness after activity
 No or little pain in AM,
but pain returns after
activity
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
tendon
 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
complications




IDDM
Smokers
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



Infection
Dehiscence
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
Conclusion
 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
presentation
 Inability to WB, mid-foot
pain, weight bearing xrays are key
Do You Need X-rays?
X-rays
Treatment
 RICE
 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
jump
 Acute compartment
syndrome
Wrestling
 Bursitis
 Shoulder injuries
 Auricular hematomas
Bursitis
 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
eardrum
 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
In
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.
Fit
should be:
Tight
fit
Be comfortable
Unrestricted breathing
Should not impede speech during competition.
Fit
is best when retained on the upper jaw and
projects backward only as far as the last molar.
Composed of a flexible, resilient material.
Cheerleading
Journal of Pediatrics 10/21/12
Academy of Pediatrics Position Paper
37,000 ER visits
last year
Sport
Designation
Better
conditioning
Availability of
trainers
Better coaching
Undergo
Physicals
Injuries
Ankle Sprain
 Ligament injury
 Ankle pain, tenderness, swelling
Ankle Sprain
Treatment
 R.I.C.E. – Rest, Ice, Compression and
Elevation
 Modify athletic activity
 Rehabilitation ROM, strengthening, flexibility,
balance
 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
exclusion.
 Jamming force on
extended PIP joint.
 Diffuse swelling with
painful movement.
injury
 Exact pathology is not
known.
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
soreness.
 Permanent residual
thickening about the
joint.
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:
(tennis,volleyball),
swimming
 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
Conclusion
 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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