Sports injuries

Last updated: August 29, 2023

Summarytoggle arrow icon

This article focuses on injuries that are commonly associated with sporting activities, but they can also occur at work or during activities of daily living. Sports injuries are usually the result of direct trauma or a sudden increased load on the joints, ligaments, and/or muscles. Acute joint and ligament injuries typically result from nonphysiological movements in the joints (e.g., excessive supination of the ankle). Treatment of acute sports injuries usually follows the POLICE principle (protection, optimal loading, ice, compression, and 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. Compression neuropathies, especially of the peripheral nerves of the upper extremity, are commonly associated with sport. In most cases, compression neuropathies can be treated with conservative management (e.g., rest, activity modification, physical therapy); surgical decompression may be considered for those with symptoms that are refractory to conservative management.

Initial management of sports injuriestoggle arrow icon

Diagnosis [1]

Treatment by injury phase [2]

The treatment strategy depends on the pathophysiological phase of the injury.

  • Acute [2]
    • Acute local inflammation
    • Clinical features: warmth, erythema, swelling, reduced function
    • Duration: typically 1–3 days
    • Treatment goals include protecting injured tissue and reducing inflammation.
  • Subacute [2]
  • Chronic [2]
    • Chronic local inflammation and/or excessive collagenous response to the original injury
    • Clinical features: pain and stiffness at rest that improves with activity
    • Treatment goals include avoiding aggravating activities, maintaining ROM, and reducing chronic inflammation.

POLICE principle [3][4]

  • Protection; : immobilization (e.g., with a brace, crutches) after a brief period of relative rest to prevent further injury
  • Optimal Loading
    • Frequent movement of the affected limb within a pain-free range in order to restore function
    • Optimal loading depends on injury location and severity.
  • Ice
    • Cool the injured area immediately. [5][6]
    • Apply an ice pack for ≤ 30 minutes each session; repeat as needed for pain control and swelling.
    • To reduce the risk of frostbite, do not apply ice directly to the skin.
  • Compression
    • Use an elastic compression bandage.
      • Apply elastic bandage distal to the injury and continue proximally
      • A change in the character of pain (e.g., sharp to throbbing pain) may indicate tissue ischemia; remove, assess, and reapply the dressing.
    • Taping (tape bandages) should not be used during the first 12–24 hours.
    • Continue compression as long as there is a risk of swelling. [2]
  • Elevation: Maintain the injured area above the level of the heart.

RICE principle

  • RICE = Rest, Ice, Compression, Elevation
  • No longer recommended because early mobilization has been shown to improve postinjury function [2]

Rehabilitation [7]

The transition from acute care to performance care often involves multiple caregivers, especially for elite athletes and/or major injuries.

  • Consider early referral to a sports medicine clinic for comprehensive care.
  • Physical therapists can assist with acute care, restoration of motion, and improved neuromuscular coordination.
  • Medically directed strength and conditioning programs may be necessary to restore full performance.

Activity modification for athletes [1][8][9]

General principles

  • Premature return to full activity can worsen acute and overuse injuries, which risks prolonging disability.
  • Adherence to activity restriction can be challenging, especially for patients who are highly motivated to continue their sport.
  • Consult a sports medicine specialist or the athlete's team physician, whenever available, to guide the activity modification plan.
  • Activities likely to exacerbate the injury are best avoided.
  • Exercises that maintain tone, ROM, and flexibility of unaffected muscles, bones, or joints are typically safe to continue.
  • A gradual return to activity is typically preferred.

Return to play (RTP)

RTP decisions are complex and involve input from healthcare providers, the patient, and parents or guardians (when applicable).

  • Criteria for RTP include:[1][8][9]
    • The status of acute or chronic injury makes further harm unlikely.
    • The sport-specific function of the injured body part has returned.
    • The individual can perform safely (may require a brace, orthotic, or equipment modification).
    • Overall musculoskeletal, cardiovascular, pulmonary, and psychological functions have been restored.
    • Participation does not put individual or other participants at risk.
    • Local and/or governing body regulations are fulfilled.
  • Minor injuries: RTP decision can be made on an individual basis by experienced general care providers.
  • Major injuries: RTP decisions are best made by sports medicine specialists.

Ankle sprainstoggle arrow icon

Definitions [10][11]

Etiology [10][11][12]

In supination injuries, the Anterior TaloFibular ligament Always Tears First.

The most common cause of an ankle sprain is a forceful inversion of the ankle that damages the lateral ligament.

Classification [10][11][12]

  • Grade I: no macroscopic changes
  • Grade II: partial tear
  • Grade III: complete tear

Clinical features [10][11][12]

Diagnosis [10][11][12]

Ankle sprain is a clinical diagnosis.

Clinical evaluation

Ottawa ankle rules

  • Used to assess whether x-rays for ankle and midfoot injuries are necessary to identify fractures. [13]
  • Ankle x-rays are typically indicated for distal malleolar tenderness and/or inability to bear weight immediately after the injury or at the time of evaluation.
  • For detailed criteria, see “Ottawa foot and ankle rules” in “Ankle fractures.”

Imaging [4]

Differential diagnosis [10]

Treatment [10][11][12]

The majority of lateral ankle sprains can be managed without surgery. [14]


  • Full recovery is likely, but recovery time is related to sprain severity. [10]
  • Chronic ankle instability and/or persistent symptoms are common. [11]
  • Proprioception and balance training prevent recurrent sprains. [11][12]

Patellofemoral pain syndrometoggle arrow icon


Clinical features [16][17][18]

Diagnosis [16][17][18]

Differential diagnosis

Treatment [16][17][18]

Medial tibial stress syndrometoggle arrow icon

Background [24][25]

  • Definition: Exercise-induced pain along the posteromedial border of the tibia; that is not the result of ischemia or a stress fracture; also known as shin splints [25]
  • Epidemiology: 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

  • Exercise-induced pain along the middle and distal posteromedial tibia
    • Early stages: Pain begins with activity and resolves during continued exercise.
    • Late stages: Pain persists during exercise and may continue at rest.
  • Tenderness of the surrounding muscles
  • Diffuse tenderness of the distal two-thirds of the posteromedial border of the tibia


Differential diagnosis of exercise-induced leg pain [25]


Knee tendon injuriestoggle arrow icon


Tendinous injuries of the knee include patellar tendon rupture or tear and quadriceps tendon rupture or tear.

Shared features

Distinguishing features

Distinguishing features of knee tendon injuries
Patellar tendon rupture Quadriceps tendon rupture
  • Direct trauma to the infrapatellar region
  • Direct trauma to the suprapatellar region
Clinical features
  • Palpable gap in tendon inferior to the patella
  • High-riding patella on examination
  • Palpable gap in tendon superior to the patella
  • Low-riding patella on examination
  • Cracking or tearing sensation
Distinguishing X-ray findings
  • Low-riding patella
  • Forward shift of the proximal pole of the patella

Signs of acute internal knee derangement can initially mask the distinguishing physical findings of knee tendon injuries and any associated knee ligament injuries.

Initial management of knee tendon injuries [4]

Patellar tendon injurytoggle arrow icon

Etiology [26][27]

  • Trauma to the infrapatellar region (most common)
  • Contraction of the quadriceps muscle with the foot planted, e.g., during a fall (rare)
  • Chronic tendon degeneration usually precedes acute rupture.

Clinical features [26][27]

Diagnostics [26][27]

  • Full knee X-ray series
    • Confirmatory findings: high-riding patella
    • Other findings: avulsion fractures, infrapatellar mass, tendon calcification (in chronic tendon degeneration)
    • Not sensitive for a partial tear of the tendon [4]
  • MRI
    • Indications: unclear diagnosis, concern for acute intraarticular damage and/or chronic tendinopathy
    • Findings: partial or complete tendon disruption, ligament or cartilage tear, hemorrhage, and/or edema
  • Ultrasound: an alternative to MRI for detecting partial tear of the tendon

Treatment [26][27]

See “Initial management of knee tendon injuries” for acute therapy.

  • Partial tears: prolonged immobilization or operative repair depending on injury characteristics [29]
  • Complete tears: operative repair within 2–3 weeks [28]

Quadriceps tendon injurytoggle arrow icon

Etiology [26][27][30]

  • Falls: eccentric contraction of the quadriceps muscle when the knee is partly flexed and the foot planted (most common)
  • Trauma (e.g., direct blow) to the suprapatellar region (rare)
  • Most common in adults aged > 40 years with systemic disease [27]

Risk factors [26][27][30]

Clinical features [26][27][30]

  • Acute intense pain
  • Inability to actively extend the knee
  • A palpable gap in the quadriceps tendon
  • Other: cracking or tearing sensation, swelling

Diagnostics [26][27][30]

  • Full knee X-ray series
    • Confirmatory finding: low-riding patella , forward shift of the proximal pole of the patella
    • Other findings: suprapatellar mass (retracted tendon), suprapatellar calcification (avulsed bone)
    • Not sensitive for a partial tear of the tendon [4]
  • MRI
    • Indications: unclear diagnosis, concern for acute intraarticular damage and/or chronic tendinopathy
    • Findings: partial or complete tendon disruption, ligament or cartilage tear, hemorrhage, and/or edema
  • Ultrasound: an alternative to MRI for detecting a partial tear of the tendon

Treatment [26][27][30]

See “Initial management of knee tendon injuries” for acute therapy.

Muscle injuriestoggle arrow icon

Muscle strain [31][32][33]

  • Definition: injury to myofibers resulting from forceful contraction or excessive stretching [4][32]
  • Etiology
    • Muscles are stretched beyond the elastic limit during active contraction.
    • Site of injury is usually at the musculotendinous junction.
  • Classification [33][34]
    • Grade I: < 5% of muscle fibers are damaged.
    • Grade II: 5–99% of muscle fibers are torn (incomplete rupture).
    • Grade III: complete tear of muscle or tendon
  • Clinical features [4][33]
    • Acute pain exacerbated by active contraction or passive stretching
    • Swelling
    • Tenderness to palpation
    • Ecchymosis or palpable hematoma
    • Loss of muscle function
    • Palpable defect in the muscle body
  • Diagnostics: primarily a clinical diagnosis [32][33][35]
  • Treatment [31][32]
  • Prognosis [37]
    • Grade II strains: healing within 2–3 weeks; return to activity in ≥ 4 weeks
    • Grade III strains: healing within 4–6 weeks; require rehabilitation for 4–6 months

Muscle contusion [38][39]

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. [40][41]
  • 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.

Compression neuropathiestoggle arrow icon

Upper extremity neuropathies [42][43]

Upper extremity neuropathies in sport [42][43]
Associated sport
Median nerve entrapment Carpal tunnel syndrome
  • Cycling
  • Wheelchair sports
  • Football
Pronator syndrome
  • Archery
  • Tennis
Ulnar nerve entrapment Ulnar tunnel syndrome
  • Cycling (known as handlebar palsy)
  • Raquet sports
  • Golf
  • Wheelchair sports
  • Weight lifting
Cubital tunnel syndrome
  • Baseball
  • Bodybuilding
  • Football
Radial nerve entrapment Posterior interosseous nerve syndrome
  • Swimming
  • Gymnastics
  • Tennis
Radial tunnel syndrome
  • Tennis
  • Bodybuilding

Axillary nerve palsy (rare)

Quadrilateral space syndrome
  • Baseball
  • Volleyball
Suprascapular nerve neuropathy
  • Volleyball
  • Baseball (especially in pitchers)
  • Weight lifting

Lower extremity neuropathies [44]

Lower extremity neuropathies in sport [44]
Associated sport
Common peroneal neuropathy
  • Repeated or prolonged squatting [45]
Tarsal tunnel syndrome
  • Long-distance running [46]
Meralgia paresthetica [47]
  • Gymnastics
  • Football
  • Bodybuilding

Management [42][43][44]

Diagnosis is primarily clinical. Electrodiagnostic studies may be required in individuals with atypical presentation or symptoms refractory to conservative management. See “Peripheral nerve injuries” for details.

Referencestoggle arrow icon

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