SPORT INJURY

Dr. Meiky Fredianto Sp.OT

SPORT MEDICINE
 Injury prevention
 Diagnosis

 Treatment and

 Rehabilitation
SPORT MEDICINE TEAM
 Orthopaedic surgeon
 Family physician
 Physiotherapist/ physical therapist
 Sport physician
 Massage therapist
 Radiologist
 Podiatrist
 Dietitian/ nutritionist
 Psychologist
 Sport trainer/ athletic trainer
 Other professionals
 Coach
 Fitness adviser
THE CHALLENGES OF MANAGEMENT
 Secret success sport medicine  broad view
patient and the problem, narrow view short term
amelioration of symptom but will ultimately lead
to failure
 Two main challenges
 Diagnosis  problem and cause
 Treatment
SPORT INJURIES
 Physical activity  activity-related injury
 Acute injury vs overuse injury

 Depend mechanism of injury and onset of

symptoms
ACUTE INJURIES
 Extrinsic causes vs intrinsic causes
 Classified according particular site injured and
type of injury :
 Bone
 Articular cartilage
 Joint
 Ligament
 Muscle
 Tendon
 Bursa
 Nerve
 skin
BONE
 Fracture
 Periosteal contusion
ARTICULAR CARTILAGE
 Osteochondral/ chondral fractures
 Minor osteochondral injury
JOINT
 Dislocation
 subluxation
LIGAMENT
 Sprain/ tear (grades I-III)
MUSCLE
 Strain/ tear (grades I-III)
 Contusion

 Cramp

 Acute compartment syndrome

TENDON
 Tear
 Complete
 Partial
BURSA
 Traumatic bursitis
NERVE
 Neuropraxia
SKIN
 Laceration
 Abrasion

 Puncture wound
OVERUSE INJURIES
 Three distinct challenges
 Diagnosis
 Treatment
 Understanding why the injury occured

 Cause
 Extrinsic
 Intrinsic
EXTRINSIC CAUSE
 Training errors
 Surfaces

 Shoes

 Equipment

 Environmental

 Condition

 Psychological factors

 Inadequate nutrition
INTRINSIC FACTORS
 Malalignment
 Leg length discrepancy

 Muscle imbalance

 Muscle weakness

 Lack of flexibility

 Sex, size, body composition

 Others
BONE
 Stress fracture
 Bone strain, stress reaction

 Osteitis, periostitis

 Apophysitis
ARTICULAR CARTILAGE
 Chondropathy
 Softening
 Fibrillation
 Fissuring
 Chondromalacia
JOINT
 Synovitis
 Osteoarthritis
LIGAMENT
 Inflammation
MUSCLE
 Chronic compartment syndrome
 Delayed onset muscle soreness

 Focal tissue thickening/ fibrosis

TENDON
 Tendinopathy
 Paratenonitis
 Tenosynovitis
 Tendinosis
 Tendinitis
BURSA
 Bursitis
NERVE
 Entrapment
 Minor nerve injury/ irritation

 Adverse neural tension

SKIN
 Blister
 Callus
KNEE
 A diarthrodial joint that allows simultaneous
rotation and translation
Overview of Knee Ligament Function
Ligament Primary function Secondary function
Anterior Cruciate Ligament Resists anterolateral displacement of Resists varus displacement at 0
(ACL) the tibia on the femur degrees of flexion
Posterior Cruciate Ligament Resists posterior tibial displacement, Resists varus displacement at 0
(PCL) especially at 90 degrees of flexion degrees of flexion
Lateral Collateral Ligament Resists varus displacement at 30 Resists posterolateral rotatory
(LCL) degrees of flexion displacement with flexion that is
less than approximately 50
degrees
Popliteofibular Ligament / Resists posterolateral rotation of the Resists varus angulation
Posterior Lateral Corner (PLC) tibia on the femur andposterior displacement of
the tibia on the femur
Medial Collateral Ligament Resists valgus angulation Works in concert with ACL to
(MCL) provide restraint
to axial rotation
ANTERIOR CRUCIATE LIGAMENT
(ACL)
 Function
 prevents anterior translation of the tibia relative to
the femur
 Anatomy
 intrasynovial
 origin
 lateral femoral condyle
 insertion
 broad and irregular
 anterior and between the intercondylar eminences of the

tibia
 two bundles
 tight in extension, loose in flexion
POSTERIOR CRUCIATE LIGAMENT
(PCL)
 Function
 prevents posterior translation of the tibia relative to
the femur
 Anatomy
 origin
 medial femoral condyle
 insertion
 tibial sulcus
 two bundles
LATERAL COLATERAL LIGAMENT
(LCL)
 Function
 to provide support to varus angulation
 works in concert with MCL to provide restraint to axial
rotation
 also known as "Fibular Collateral Ligament".
 Anatomy
 origin
 on lateral femoral condyle posterior and superior to insertion
of popliteus
 insertion
 on the fibula anterior to the popliteofibular ligament on the
fibula
 capsule's most distal extent is just posterior to the fibula
 structure
 cord-like
MEDIAL COLATERAL LIGAMENT
(MCL)
 Function
 to provide restraint to valgus angulation
 works in concert with ACL to provide restraint to
axial rotation
 Anatomy
 origin
 MFC to medial tibia extending down several centimeters
 structure
 two components
 superficial portion (tibial collateral ligament)

 deep portion (medial capsular ligament)

HISTORY AND PHYSICAL EXAM
OF THE KNEE
History Physical Exam
ACL Usually non-contact Lachman positive
Landed awkwardly Pivot shift positive
Felt "pop" Large hemarthrosis
Immediate swelling
PCL Struck dashboard Posterior sag sign
Fall with PF foot Posterior drawer (at 90° flexion)
Posterior pain Quad active test
MCL Blow to outside of knee Valgus instability
Medial pain
LCL Varus injury Varus instability
Lateral pain
PLC Lateral and posterior pain Dial test positive (at 30° flexion)
Usually combined with other
ligament injuries
Menisc Mechanical symptoms (catching, Joint line tenderness
us locking) McMurray positive
Pain at joint line
Delayed swelling
Patella Patellar apprehension
Fall with DF foot
Tender over MPFL
May feel 2 "pops"
Effusion
Swelling
Patellar crepitus
Anterior pain
Pain with active compression test
Pain with stairs
Increased Q-angle
LOOK
 Skin
 scars
 trauma
 erythema
 Swelling
 Muscle atrophy
 normal quadriceps circumference
 10 cm (VMO)
 15 cm (quadriceps)
 Asymmetry
 Gait
 antalgia
 stride length
 muscle weakness
 Standing limb alignment
 neutral, varus, valgus
FEEL
 Joint line tenderness
 Tenderness over soft tissue structures
 pes anserine bursae
 patellar tendon
 iliotibial band

 Point of maximal tenderness

 Effusion
 patella balloting
 milking
MOVE
 Active and passive
 flexion/extension normal range
 10° extension (recurvatum) to 130° flexion
 rotation varies with flexion
 in full extension, there is minimal rotation
 at 90° flexion, 45° ER and 30° IR

 abduction/adduction
 in full extension, essentially 0°
 at 30° flexion, a few degrees of passive motion possible
NEUROVASCULAR EXAM
 Sensation
 medial thigh - obturator
 anterior thigh - femoral
 posterolateral calf - sciatic
 dorsal foot - peroneal
 plantar foot - tibial
 Motor
 thigh adduction - obturator
 knee extension - femoral
 knee flexion - sciatic
 toe extension - peroneal
 toe flexion - tibial
 Vascular
 pulses
 popliteal
 dorsalis pedis
 posterior tibial
 ankle-brachial index
 ABI < 0.9 is abnormal
KNEE IMAGING
 X ray
 MRI

 Ultrasound
MENISCUS
Function :
 Force transmission
 the meniscus functions to optimize force transmission
across the knee. It does this by
 increasing congruency
 shock-absorption
 transmits 50% weight-bearing load in extension, 85% in flexion
 Stability
 the meniscus deepens tibial surface and acts as secondary
stabilizer
 medial meniscus
 lateral meniscus
 the menisci become primary stabilizers in the ACL-
deficient knee
Composition
 Made of fibroelastic cartilage
 interlacing network of collagen, proteoglycan,
glycoproteins, and cellular elements
 composed of 65-75% water

 Collagen
 90 % Type I collagen
 Fibers
 composed of two types of fibers
 radial
 longitudinal (circumferential)
Anatomy
 Gross Shape
 medial meniscus
 C-shaped with triangular cross section
 lateral meniscus
 is more circular (the horns are closer together and approximate the ACL)
 covers a larger portion of the articular surface
 Attachment
 transverse (intermeniscal) ligament
 coronary ligaments
 meniscofemoral ligament
 Blood supply
 medial inferior genicular artery
 lateral inferior genicular artery
 Innervation
 peripheral two-thirds innervated by Type I and II nerve endings
 posterior horns have highest concentration of mechanoreceptors
Injury & Healing potential
 Tears in peripheral 25% red zone
 can heal via fibrocartilage scar formation
 Tears of central 75%
 have limited or no intrinsic healing ability
MENISCAL PATHOLOGY
 Epidemiology
 most common indication for knee surgery
 higher risk in ACL deficient knees

 Location
 medial tears
 more common than lateral tears
 degenerative tears in older patients usually occur in

the posterior horn medial meniscus

 lateral tears
 more common in acute ACL tears
Classification
 Descriptive classification
 location
 red zone (outer third, vascularized)
 red-white zone (middle third)

 white zone (inner third, avascular)

 size
 pattern
 vertical/longitudinal
 bucket handle

 oblique/flap/parrot beak

 radial

 horizontal

 complex
Presentation
 Symptoms
 pain localizing to medial or lateral side
 mechanical symptoms (locking and clicking)
 delayed or intermittent swelling
 Exam
 joint line tenderness is the most sensitive physical
examination finding
 effusion
 provocative tests
 McMurray's test
 flex the knee and place a hand on medial side of knee,
externally rotate the leg and bring the knee into extension.
 a palpable pop or click is a positive test and can correlate
with a medial meniscus tear
Imaging
 Radiographs
 Should be normal in young patients with an acute
meniscal injury
 Meniscal calcifications may be seen in crystalline
arthropathy (ex. CPPD)
 MRI
 indications
 MRI is most sensitive diagnostic test, but also has a high
false positive rate
 findings
 parameniscal cyst indicates the presence of a meniscal tear
 may see "double PCL" sign that indicates a bucket-handle
meniscal tear
 Non-operative
 rest, NSAIDS, rehabilitation
 indications
 indicated as first line of treatment for degenerative tears

 Operative
 partial meniscectomy
 meniscal repair
 meniscal transplantation
 total meniscectomy
ACHILLES TENDON RUPTURE
 Acute rupture of the achilles tendon
 often misdiagnosed as an ankle sprain
 may be missed in up to 25%
 Epidemiology
 incidence
 18:100,000 per year
 demographics
 more common in men
 most common in ages 30-40
 risk factors
 episodic athletes, "weekend warrior"
 flouroquinolone antibiotics
 steroid injections
 The condition is often associated with poor muscle strength and
flexibility
 Failure to warm up and stretch before sport
 Previous injury or tendinitis
 Mechanism
 usually traumatic injury during a sporting event
 may occur with
 sudden forced plantar flexion
 violent dorsiflexion in a plantar flexed foot

 Pathoanatomy
 rupture usually occurs 4-6 cm above the calcaneal
insertion in hypovascular region
ANATOMY
 Achilles tendon
 largest tendon in body
 formed by the confluence of
 soleus muscle tendon
 medial and lateral gastrocnemius tendons

 blood supply from posterior tibial artery

PRESENTATION
 History
 patient usually reports a "pop"
 Symptoms
 weakness and difficulty walking
 pain in heel
 Physical exam
 inspection
 increased resting ankle dorsiflexion in prone position with
knees bent
 calf atrophy may be apparent in chronic cases
 palpation
 palpable gap
 motion
 weakness to ankle plantar flexion
 provocative test
 Thompson test
 lack of plantar flexion when calf is squeezed
IMAGING
 Radiographs
 indications
 used to rule out other pathology

 Ultrasound
 indications
 may be useful to determine complete vs. partial ruptures
 MRI
 indications
 equivocal physical exam findings
 chronic ruptures

 findings
 will show acute rupture with retracted tendon edges
TREATMENT
 Nonoperative
 functional bracing/casting in resting equinus
 indications
 acute injuries with surgeon or patient preference for non-

operative management
 sedentary patient

 medically frail patients

 Operative
 end-to-end achilles tendon repair
 percutaneous achilles tendon repair
 reconstruction with VY advancement
 flexor hallucis longus transfer +/- VY advancement of
gastrocnemius
ACHILLES TENDONITIS
 Mechanism
 overuse
 imbalance of dorsiflexors and plantar flexors
 poor tendon blood supply
 genetic predisposition
 fluoroquinolone antibiotics
 inflammatory arthropathy
 Pathophysiology
 theorized to be due to abnormal vascularity 2 to 6 cm
proximal to Achilles insertion in response to
repetitive microscopic tearing of the tendon
 Presentation
 symptoms
 pain, swelling, warmth
 worse symptoms with activity

 difficulty running

 physical exam
 tendon thickening and tenderness 2 to 6 cm proximal to
Achilles insertion
 pain throughout entire range of motion
 Imaging
 MRI
 disorganized tissue will show up as intrasubstance
intermediate signal intensity
 thickened tendon

 chronic rupture will show a hypoechoic region between

tendon ends
 Treatment
 nonoperative
 activity modification, shoe wear modification, therapy, NSAIDs
 indications

 first line of treatment

 techniques
 therapy
 physical therapy with eccentric training modalities (iontophoresis,
phonophoresis, and ultrasound)
 shoewearheel lifts
 cast or removable boot (severe disease)
 outcomes
 nonoperative management is 65% to 90% successful

 operative
 percutaneous tenotomies
 open excision of degenerative tendon with tubularization
 tendon transfer (FHL, FDL, or PB)
LOW ANKLE SPRAIN
 Epidemiology
 ankle sprains are the most common reason for missed
athletic participation
 most common injury in dancers
 Associated injuries include
 osteochondral defects
 peroneal tendon injuries
 subtle cavovarus foot
 deltoid ligament injury (isolated deltoid ligament
injuries are very rare)
 fractures
 5th metatarsal base
 anterior process of calcaneus

 lateral or posterior process of the talus

PRESENTATION
 Symptoms
 pain with weight bearing
 recurrent instability
 catching or popping sensation may occur following
recurrent sprains
 Physical exam
 focal tenderness and swelling over involved
ligament(s)
 anterior drawer test
 possible laxity with anterior drawer and eversion/inversion
stress testing
IMAGING
 Radiographs
 indications for radiographs with an ankle injury include (Ottawa
ankle rules)
 inability to bear weight
 medial or lateral malleolus point tenderness
 5MT base tenderness
 navicular tenderness
 radiographic views to obtain
 standard ankle series (weight bearing)
 AP
 lateral

 mortise

 ER rotation stress view

 varus stress view
 MRI
 indications
 consider MRI if pain persists for 8 weeks following sprain

 useful to evaluate
 peroneal tendon pathology
 osteochondral injury
TREATMENT
 Nonoperative
 RICE, elastic wrap to minimize swelling, followed by therapy
 indications
 Grade I, II, and III injuries

 technique
 may require short period (approx. 1 week) of weight-bearing
immobilization in a walking boot or walking cast, but early mobilization
facilitates a better recovery
 therapy
 once swelling and pain have subsided and patient has full range of motion
begin neuromuscular training with a focus on peroneal muscles strength
and proprioception training
 a functional brace that controls inversion and eversion is typically used
during the strengthening period and used as prophylactic treatment
during high risk activities thereafter
 early functional rehabilitation allows for quickest return to physical
activity
 Operative
 anatomic reconstruction vs. tendon transfer with tenodesis
 arthroscopy