Sports injuries

Sports injuries are usually the result of a sudden increased load on the joints, ligaments, and/or muscles. Acute joint and ligament injuries typically result from non-physiological movements in the joints. (e.g., twisting the ankle → supination injury). Treatment of acute sport injuries usually follows the POLICE principle (protection, offloading, ice, compression, elevation). Definitive therapy depends on the extent of the injury (e.g., the presence or absence of fractures) and ranges from immobilization of the affected region (e.g., casts, braces, supportive wraps) to surgical repair.

• List of topics covered in this article
  • Injuries to the bones, tendons, and ligaments
    • Quadriceps tendon rupture
    • Patellar tendon rupture
    • Injuries to ankle ligaments
  • Muscle injuries
    • Delayed onset muscle soreness
    • Muscle strain
  • Acute management of sports injuries
• Sport injuries covered in other articles
  • Finger injuries
  • Meniscal tears
  • Knee ligament injuries
  • Achilles tendon rupture
  • Ankle fracture

Injuries to ankle ligaments ^[1]

• Etiology
  • Supination injury to the ankle joint (overinversion) ; → sprain of the lateral ligament complex
    • The anterior talofibular ligament (ATFL) is the most commonly affected in low ankle sprains (and ankle sprains overall).
    • The anterior inferior tibiofibular ligament is most commonly involved in high ankle sprains.
  • Pronation injury → sprain of the medial ligament complex (deltoid ligament)
• Classification
  • Grade I: no macroscopic changes
  • Grade II: partial tear
  • Grade III: complete tear
• Clinical features
  • Soft tissue swelling, limited range of movement at the ankle joint, hematoma
  • Tenderness over the sprained ligament
  • ↑ Joint laxity and a prominent talus (when compared with the normal ankle)
• Diagnostics
  • Assess for neurovascular compromise
  • Decision to x-ray is based on the Ottawa ankle rules (see “Acute management of sports injuries” below)
• Treatment
  • Conservative therapy
    • Initially: POLICE principle
    • Later
      • In cases of severe pain and/or instability: Grade II may require a cast boot and grade III may require a short leg cast for a few days.
      • In cases of fractures: short leg cast
  • Surgical treatment
    • Sprain of the lateral ligament complex: only in severe cases
    • Sprain of the medial ligament (deltoid ligament): A tear in the deltoid ligament often requires surgical repair.
    • Failure of conservative treatment
• Differential diagnosis: ankle fracture
• Prognosis
  • Most ankle sprains heal well.
  • Recurrent ankle sprains may lead to ankle instability, which may require surgical reconstruction of the ankle ligaments (e.g., periosteal flaps).
  • The recurrence of an ankle sprain can be prevented by proprioceptive training.

The most common cause of an ankle sprain is a forceful inversion injury.

In ankle sprains, the Anterior TaloFibular ligament Always Tears First.

Patellofemoral pain syndrome ^[2]

• Epidemiology
  • One of the most common causes of anterior knee pain
  • Common in young athletes
  • ♀ > ♂
• Etiology
  • Overuse
  • Malalignment of the knee joint
  • Chondromalacia patellae: damage (softening, fragmentation, or erosion) of the articular cartilage of the patella due to excessive overuse (especially during flexion) or trauma
• Clinical features
  • Retropatellar or peripatellar pain that worsens with knee flexion during weight-bearing activity (e.g., ascending and descending stairs, jumping, running) or after periods of prolonged sitting
  • Crepitus when knee is flexed
  • Clinical examination: positive patellar grind test
• Diagnostics
  • Clinical diagnosis
  • X-ray in case of findings that suggest an alternative diagnosis (e.g., recent trauma, joint instability, joint effusion) or to exclude other pathologies (e.g., osteoarthritis, patellar fracture, osteochondritis)
• Treatment
  • Acute phase
    • POLICE principle
    • NSAIDs
  • Recovery phase
    • Physical therapy (e.g., quadriceps strengthening)
    • Switching to low-impact activities (e.g., biking, swimming)
    • Weight loss
    • Insoles
  • Surgery: only in severe cases

The patellar grind test is less effective than other tests at diagnosing patellofemoral pain syndrome and may cause the patient unnecessary pain.

Medial tibial stress syndrome (shin splints)

• Epidemiology
  • One of the most common causes of painful shins
  • Common in runners and military recruits
• Etiology: overuse injury
• Pathophysiology: periostitis with an imbalance of bone formation and resorption in the tibial cortex, which causes increased bone degradation
• Clinical features
  • Diffuse pain of the middle and distal posteromedial tibia
  • Tenderness of the surrounding muscles
• Treatment: conservative

Patellar tendon rupture

• Etiology
  • Trauma to the infrapatellar region (common)
  • Rarely as a result of contraction of the quadriceps muscle with the foot planted (e.g., due to a fall)
  • Chronic tendon degeneration
• Clinical features
  • Pain and swelling of the knee joint
  • A high-riding patella
  • A palpable gap in the quadriceps tendon
  • Inability to extend the knee
• Diagnostics
  • X-ray (AP, lateral, axial)
    • A high-riding patella
    • Calcification seen in chronic causes
  • Ultrasound: hypoechogenic section seen across the tendon (suggests an acute tear)
  • MRI
    • Used if other techniques are inconclusive
    • Shows disrupted tendon fibers with adjacent hemorrhage or edema
• Treatment
  • Partial tears: immobilization
  • Complete tears: surgical end-to-end suturing of the patellar tendon with a wire cerclage between the patellar tendon and tibial tuberosity (McLaughlin cerclage) to protect the sutures ^[3]

Quadriceps tendon rupture

• Etiology
  • Commonly a result of eccentric contraction of the quadriceps muscle when the knee is partly flexed and the foot planted (e.g., during falls)
  • Trauma (e.g., direct blow) to the suprapatellar region (rare)
• Risk factors
  • Hyperparathyroidism
  • Gout
  • SLE
  • Rheumatoid arthritis
  • Diabetes
  • Glucocorticoid therapy
• Clinical features
  • Pain and swelling of the knee joint
  • A palpable gap in the quadriceps tendon
  • Inability to extend the knee
• Diagnostics
  • X-ray (AP and lateral view): lack of quadriceps shadow, suprapatellar mass present
  • Ultrasound: hypoechogenic section seen across the tendon
  • MRI
    • Used if other techniques are inconclusive
    • Shows tear across all three layers of the tendon
• Treatment: surgical repair (suturing) of the quadriceps tendon with follow-up physical therapy

Delayed onset muscle soreness

• Definition: painful feeling of tension in the muscles 1–2 days after increased physical activity
• Etiology
  • Climbing uphill
  • Eccentric strength training
  • Sports that involve jumping, acceleration, deceleration, and sudden changes in direction
• Pathophysiology
  • Microtears close to the Z-line of the sarcomere → stimulation of muscle hypertrophy
  • If the load or the level of physical activity is too high → inflammatory reaction near the Z-line → greater muscle repair and less muscle hypertrophy and pain due to muscle edema
  • Based on current knowledge, the build-up of lactate does not play a role in muscle soreness. ^[4][5]
• Clinical features
  • Pain on moving and/or stretching the affected muscles, muscle tenderness
  • Pain peaks after 1–3 days
  • Muscle stiffness
• Diagnostics: clinical diagnosis
• Treatment:
  • Avoid rest
  • Cycling, jogging at low intensity
  • Warmth (e.g., applied heat)
  • Careful passive stretching
• Prognosis: Spontaneous healing usually occurs within a few days.

Muscle strain

• Definition: excessive stretching of a muscle, which can lead to a tear
• Etiology
  • Longitudinal stretching of the muscle to a point beyond the elastic limit during active contraction
  • The musculotendinous junction is the most common site of injury.
• Classification ^[6]
  • Grade I: < 5% of muscle fibers are damaged.
  • Grade II: Numerous muscle fibers are torn (incomplete rupture).
  • Grade III: complete tear of muscle or tendon
• Clinical features
  • Acute-onset pain, which is present at rest and exacerbated by movement
  • Swelling of the muscle
  • Tenderness to palpation
  • Visible hematoma
  • Loss of function in the affected muscle for grades II and III
  • Palpable dent in the muscle for grade III injury
• Diagnostics
  • X-ray: to rule out fracture or dislocation
  • MRI: to determine if a full rupture is present
• Treatment
  • POLICE principle
  • NSAIDS
  • Grade III strains may require surgery to reattach the muscle.
• Prognosis: Grade I strains may recover spontaneously within a couple of weeks, while high grade strains may take months.

The RICE principle advocated complete rest (R) of the injured musculoskeletal area whereas the POLICE principle (see below) recommends protection (P) and optimal loading (OL) of the injured area to stimulate healing and avoid muscle/joint stiffness and atrophy, which can occur after prolonged periods of rest. The “ICE” of both principles remains the same.

• POLICE principle ^[7]
  • Protection; : After an initial period of rest, protect the injured area with a brace or cast to allow for mobilization without further damage.
  • Optimal Loading
    • Controlled increments of mechanical stress to the affected limb (instead of complete rest or immobilization).
    • The optimal loading strategy differs by affected area and severity of the injury.
    • For a lower limb injury, limited weight-bearing may be achieved through orthopedic devices such as crutches or walking boots.
  • Ice
    • Cool the affected area for 20–30 min, followed by a break, and resume after a couple of hours.
    • Ice should not be directly applied to the skin (due to risk of frostbite)
  • Compression
    • The affected limb/joint should rest in a position that minimizes pain.
    • Elastic bandage (wrapped in a caudal to cranial direction)
    • A change in the character of pain (throbbing pain) may imply that the bandage is too tight (the bandage should then be removed and reapplied after 5–10 min)
    • Taping (tape bandages) should not be used during the first 12–24 hours.
  • Elevation: The extremities should be raised above the level of the heart, if feasible.
• Additional measures
  • Alcohol should not be consumed for at least 24 hours after injury. ^[8]
  • Saunas and warm baths increase circulation in the injured region and should not be used during the initial period after injury.

• Ottawa ankle rules: used to indicate whether x-ray for ankle and midfoot injuries is necessary ^[9]
  • X-ray (plain) of the ankle is indicated when the patient experiences pain in the malleolar region and has one of the following features:
    • Tenderness at the posterior border or tip of the lateral malleolus
    • Tenderness at the posterior border or tip of the medial malleolus
    • Inability to bear weight