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Sports Injuries Andrew O’Brien Tom Milligan
Scenario A 40 year old male is asked to play in a work 5 a-side football match. He hasn’t 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 Tendinopathy • Previously termed Achilles tendinitis but studies suggest no prostaglandin mediated inflammation • Term encompasses pain, swelling, weakness and stiffness of the Achilles • Repeated overloading causes degeneration & disorganized collagen fibre laydown • Thought to occur when imbalance between degeneration & repair leading to tearing & pain • Usually occurs at mid-portion of tendon (site of AT rupture) • Can have associated inflammation of retrocalcaneal bursa
Diagnosis History • Pain in mid portion of tendon • Pain related to exercise (often at start and after exercise with diminished discomfort during exercise) • Stiffness of tendon in morning • Often unaccustomed to or increased intensity of exercise • Can interfere with daily living activity Examination • Look for deformity & swelling • Palpate swelling, nodularity, heat and creps. • Exclude rupture
Management • Expectation 3-6 months to resolve • Discontinue quinolones/consider steroid use • Initial period rest until pain subsides • NSAIDS should be limited to 14 days use • AT stretching exercises • DO NOT Inject tendon • Consider referral to physio for biomechanical assessment • Consider referral to MSK or ortho’s if not settled at 3-6 months
Stretches AT stretches: hold for 30 secs, rpt x3, twice daily Wall Push Ups: try and hold lean for 30 secs, x 10, Twice daily Stair stretch: 30 seconds x 6, twice daily
Management In Secondary Care • Extracorporeal shock wave therapy • Iontophoresis, phonophoresis, sclerosant, GTN patch, growth factor injections all have weak evidence. • Surgery – includes nodule & adhesion excision, longitudinal incision.
Achilles Tendon Rupture Predisposing Factors • Age 30 – 50 • Steroids • Fluoroquinolones • Tendinopathy • Haglunds Deformity • Running Sports
History • Abrupt change of direction • Often Patient unaccustomed to sport • Often patient thinks struck at back of ankle
Diagnosis • Simmonds/Thompsons/Squeeze Test • Palpation - Rupture at 3 to 6cm
Treatment • All Cases Referred to Orthopaedics • Treatment Equinus casting vs Surgical repair • Decision depends on patient choice and activity level
Scenario 2 A 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 run You note she is tender on the medial border of her tibias in the mid/upper 1/3 What advice would you give and what is your management plan?
Shin Splints • Medial Tibial Stress Syndrome/Shin Splints • Not Specific Diagnosis - Refers to pain along the course of the tibia • Cause is thought to be related to overloading muscles of the lower limb and biomechanical irregularities • Encompasses 3 main entities: • Medial Tibial Stress Syndrome • Chronic compartment syndrome • Tibialstress fracture
MTSS • Most Common Running injury – accounts 15% • Inflammation of tendon insertions to tibial periosteum • Pain is in distribution of Sharpey Fibres that connect Soleus fascia through periosteum of tibia • Increased 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 Factors • Repetitive trauma sports e.g. running & gymnastics • Female • Low aerobic fitness • Over Pronation Feet • Tight calf muscles • Sudden Increases activity level
MTSS • MTSS consequence of repetitive stress by impact forces that fatigue soleus • Causes bending or bowing of Tibia overloading bone remodeling capabilities of Tibia • Stress microfractures can be created which aren’t seen on XRAY
Diagnosis • History • Examnation – tenderness of tibia • XRAY • CT/MRI
Management • Shock Absorbent insoles • Control overpronation • Training Error Avoidance • Rest (up to 3/12) • Crutches • NSAIDS • Physio for lower limb muscle strengthening and graduated training programs.
Aims • To have a working knowledge of knee anatomy to explain common injuries to patients • To appropriately refer knee meniscal injuries • Be aware of patella tendonitis • Objectives • Be able to draw a schematic diagram of a knee • To be able to diagnose meniscal injuries and know the difference between sports injuries and fragility tears • Know Diagnosis and treatment for patella tendonitis.
Case 1 A 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 Injuries • Are there mechanical symptoms • Fragility tear or not • Referral Options: • Haemarthrosis • Arthroscopy without imaging • Imaging
Case 2 An 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 see B. Refer to physio C. X-ray
Case 3 25 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?
Patella tendinitis One of the commonest tendinopathies Rest, Ice, NSAIDS, Stretches before future exercise Eccentric loading exercises Refer to physio.