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Sports injuries

Last updated: February 11, 2021

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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.

Injuries to ankle ligaments [1]

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

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

Patellofemoral pain syndrome (runner's knee) [2]

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
  • 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

Quadriceps tendon rupture

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
  • 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]
  1. Trauma X-Ray - Lower Limb. http://www.radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_trauma_lower_limb/ankle_fracture_x-ray. . Accessed: May 23, 2017.
  2. Gaitonde DY, Erickson A. Patellofemoral Pain Syndrome. Am Fam Physician. 2019; 99 (2): p.88-94.
  3. Patella: Open Reduction; Salvage Techniques. https://www2.aofoundation.org/wps/portal/surgery?showPage=redfix&bone=Knee&segment=Patella&classification=34-C2&treatment=&method=ORIF%20-%20Open%20reduction%20internal%20fixation&implantstype=Salvage%20techniques&approach=&redfix_url=1285238823632&Language=en. Updated: March 12, 2008. Accessed: May 22, 2017.
  4. Kim J, Lee J. A review of nutritional intervention on delayed onset muscle soreness. Part I. J Exerc Rehabil. 2014; 10 (6): p.349-356. doi: 10.12965/jer.140179 . | Open in Read by QxMD
  5. Mizumura K, Taguchi T. Delayed onset muscle soreness: Involvement of neurotrophic factors. Send to J Physiol Sci. 2015; 66 (1): p.43-52. doi: 10.1007/s12576-015-0397-0 . | Open in Read by QxMD
  6. Quaglia A, Canata G, Zaffagnini S, Grassi A. An update on the grading of muscle injuries: a narrative review from clinical to comprehensive systems. Joints. 2016; 04 (01): p.039-046. doi: 10.11138/jts/2016.4.1.039 . | Open in Read by QxMD
  7. Bleakley CM, Glasgow P, MacAuley DC. PRICE needs updating, should we call the POLICE?. Br J Sports Med. 2011; 46 (4): p.220-221. doi: 10.1136/bjsports-2011-090297 . | Open in Read by QxMD
  8. Barnes MJ. Alcohol: Impact on sports performance and recovery in male athletes. Sports Med. 2014; 44 (7): p.909-919. doi: 10.1007/s40279-014-0192-8 . | Open in Read by QxMD
  9. RES Pires, AA Pereira, GM Abreu-e-Silva, PJ Labronici, LB Figueiredo, AL Godoy-Santos, and M Kfuri. Ottawa Ankle Rules and Subjective Surgeon Perception to Evaluate Radiograph Necessity Following Foot and Ankle Sprain. Annals of Medical and Health Science Research. 2014 .
  10. Van den Bekerom MPJ, Struijs PAA, Blankevoort L, Welling L, van Dijk CN, Kerkhoffs GMMJ. What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults?. J Athl Train. 2012; 47 (4): p.435-443. doi: 10.4085/1062-6050-47.4.14 . | Open in Read by QxMD