Sports InjuriesAndrew OBrienTom Milligan

ScenarioA 40 year old male is asked to play in a work 5 a-side football match. He hasnt played for a number of years but used to play regular 5 a side in his twenties.

3 minutes into the game he felt he was kicked in the right heel and had to stop playing. The other players denied making any contact at the time. He comes to see you the next day as he has had difficulty walking since.

What is your provisional diagnosis?What tests would you perform?

Achilles TendinopathyPreviously termed Achilles tendinitis but studies suggest no prostaglandin mediated inflammationTerm encompasses pain, swelling, weakness and stiffness of the Achilles Repeated overloading causes degeneration & disorganized collagen fibre laydownThought to occur when imbalance between degeneration & repair leading to tearing & painUsually occurs at mid-portion of tendon (site of AT rupture) Can have associated inflammation of retrocalcaneal bursa

DiagnosisHistoryPain in mid portion of tendonPain related to exercise (often at start and after exercise with diminished discomfort during exercise)Stiffness of tendon in morningOften unaccustomed to or increased intensity of exercise Can interfere with daily living activityExaminationLook for deformity & swellingPalpate swelling, nodularity, heat and creps.Exclude rupture

ManagementExpectation 3-6 months to resolveDiscontinue quinolones/consider steroid useInitial period rest until pain subsidesNSAIDS should be limited to 14 days useAT stretching exercisesDO NOT Inject tendonConsider referral to physio for biomechanical assessmentConsider referral to MSK or orthos if not settled at 3-6 months

StretchesAT stretches: hold for 30 secs, rpt x3, twice dailyWall Push Ups: try and hold lean for 30 secs, x 10, Twice daily Stair stretch: 30 seconds x 6, twice daily

Spiderman Rehab

Management In Secondary CareExtracorporeal shock wave therapyIontophoresis, phonophoresis, sclerosant, GTN patch, growth factor injections all have weak evidence.Surgery includes nodule & adhesion excision, longitudinal incision.

Achilles Tendon Rupture Predisposing FactorsAge 30 50SteroidsFluoroquinolonesTendinopathyHaglunds DeformityRunning Sports

HistoryAbrupt change of direction

Often Patient unaccustomed to sport

Often patient thinks struck at back of ankle

DiagnosisSimmonds/Thompsons/Squeeze Test

Palpation - Rupture at 3 to 6cm

TreatmentAll Cases Referred to Orthopaedics

Treatment Equinus casting vs Surgical repair

Decision depends on patient choice and activity level

Scenario 2A 17 year old girl comes to see you c/o pain in her lower legs. She has been in the school athletics team for 4 years and has recently started training for the london marathon. She says she has pain in her lower legs and points to the middle 1/3 of her tibias. It comes on if she runs any more than 4 or 5 miles and can last for days after the runYou note she is tender on the medial border of her tibias in the mid/upper 1/3What advice would you give and what is your management plan?

Shin SplintsMedial Tibial Stress Syndrome/Shin SplintsNot Specific Diagnosis - Refers to pain along the course of the tibiaCause is thought to be related to overloading muscles of the lower limb and biomechanical irregularitiesEncompasses 3 main entities:Medial Tibial Stress SyndromeChronic compartment syndromeTibial stress fracture

MTSSMost Common Running injury accounts 15%Inflammation of tendon insertions to tibial periosteumPain is in distribution of Sharpey Fibres that connect Soleus fascia through periosteum of tibiaIncreased foot pronation, varus tendancy of forefoot, increased strength of plantar flexors, inadequate Ca intake, hard or inclined running surfaces, inadequate shoes and previous injury all implicated

MTSS Risk FactorsRepetitive trauma sports e.g. running & gymnasticsFemaleLow aerobic fitnessOver Pronation FeetTight calf musclesSudden Increases activity level

MTSSMTSS consequence of repetitive stress by impact forces that fatigue soleusCauses bending or bowing of Tibia overloading bone remodeling capabilities of TibiaStress microfractures can be created which arent seen on XRAY

DiagnosisHistory Examnation tenderness of tibiaXRAY CT/MRI

ManagementShock Absorbent insolesControl overpronation Training Error AvoidanceRest (up to 3/12)CrutchesNSAIDSPhysio for lower limb muscle strengthening and graduated training programs.

Knee Sports injuries

AimsTo have a working knowledge of knee anatomy to explain common injuries to patientsTo appropriately refer knee meniscal injuriesBe aware of patella tendonitisObjectivesBe able to draw a schematic diagram of a kneeTo be able to diagnose meniscal injuries and know the difference between sports injuries and fragility tearsKnow Diagnosis and treatment for patella tendonitis.

Anatomy

Case 1A 23 year old footballer has had a twisting injury to the knee which has now locked and become swollen. He can weight-bare with pain. You see him a week after the injury.

What do you want to know?What treatments are available?Are the treatment different if he were 60?

Meniscus InjuriesAre there mechanical symptomsFragility tear or not

Referral Options:HaemarthrosisArthroscopy without imagingImaging

Case 2An 13 year old boy has persistent pain in his knee following a minor trauma two weeks ago. You can find no locking, effusion, instability. He can walk with minor discomfort. Would you:A. Wait and seeB. Refer to physioC. X-ray

Case 325 year old man with anterior knee pain. When you examine him he can straight leg raise, has no effusion or locking or crepitus but has point tenderness on the distal pole of the patella.

What is wrong?How do we treat this?

http://www.youtube.com/watch?v=hqNC3sXzJII&feature=relmfuhttp://www.youtube.com/watch?v=ul09qA4hJQg&feature=related

Patella tendinitisOne of the commonest tendinopathiesRest, Ice, NSAIDS, Stretches before future exerciseEccentric loading exercisesRefer to physio.

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