SPORTS INJURY Locations of High-Risk Stress Fractures

Dr. Wilangelo Mana-ay Femoral neck

Patella (superior lateral)
STRESS FRACTURES Anterior tibial diaphysis
Medial malleolus
o Common in highly committed athletes
Talus
o More common sites:
Tarsal navicular
 tibia
Fifth metatarsal
 metatarsals Sesamoids
o Occurs in <1% of the general athletic population
o Occurs in 10-20% in running tract athletes
Treatment Principles
o Evaluation of the athletes biologic bone healing capacity
Pathophysiology
that includes review of athletes nutritional, hormonal,
o Concept of stress fracture first described by in 1850 by
medication status
Breithaupt
o “Female athlete triad” must be considered in any female
o “March fracture” observe in metatarsals of marching
athlete with stress fractures
soldiers o Female athlete triad – osteoporosis, eating disorder,
o Considered as fatigue failure of bone hormonal dysfunction
o Result from accumulation of microdamage that occurs o Fracture site must also be protected from future strain
in repetitive loading of bone
episodes through rest, bracing, technique modification,
surgical fixation (stable)
crack initiation
o Use of biophysical enhancement technologies such as
pulsed UTZ and electrical stimulation (in studies, they
crack propagation
enhance the healing capacity of the bone)
catastrophic failure (fracture in bone)
ACUTE ANKLE INJURY
Evaluation Acute Lateral Ankle Instability
o Insidious onset of pain o “Ankle Sprain”
o History of prolonged level of activity or recent rapid o One of the most common sports related injury
increase in activity o Classified into three grades depending on the severity of
o On PE, presence of pain on direct palpation or ligamentous disruption
mechanical loading of the affected site
Anatomy
Imaging studies Lateral ankle ligaments - made up of three ligaments
o Plain radiograph – you can diagnose stress fractures
readily, but sometimes others are requested
o Bone scan
o MRI
o CT scan

1. Anterior Talofibular Liogament (ATFL) - which extends

from anterior aspect of distal fibula to body of talus
 Strain increases with plantar flexion, inversion,
internal rotation
 The most ligament to be damaged is the anterior
talofibular ligament
2. Calcaneofibular (CFL) - extends from tip of fibula
posterior to its insertion on lateral calcaneus
(A) proximal aspect of tibia, (B) metatarsal area of foot, with
 Increase strain with dorsiflexion and Inversion
beginning callus formation
3. Posterior Talofibular Ligament (PTFL) - originates at
posterior fibula and inserts at posterolateral talus
CLASSIFICATION OF ACUTE LATERAL ANKLE INSTABILITY Imaging
Swelling, Pain on o Plain radiographs of ankle
Ligamentous - Ankle mortise, lateral views
Grade Ecchymosis, Weight
Disruption
Tenderness Bearing o Positive talar tilt: stress radiographs show >3 deg of tilt
compared with opposite side
I None Minimal None
o Positive anterior drawer: stress radiographs show 3mm
Stretch without greater translation compared with opposite side
II Moderate Mild
rupture o MRI can show ligamentous disruption but they provide
III Complete rupture Severe Severe no distinct advantage over PE
- Most useful in looking for other pathology
Evauation
o History suggestive of inversion injury Associated injuries
o Localized tenderness, swelling, ecchymosis over the o Osteochondritis dissecans lesions
anterior talofibular ligament (ATFL) and/or o Loose bodies
calcaneofibular ligament (CFL) o Peroneal pathology
o Examination should localized pain on lateral ankle Treatment
o Commonly in history, patients twisted their ankle o RICE- rest, ice, compression, elevation
o Most commonly injured – ATFL (weakest of all collateral o Early weight bearing and use of protective brace during
ligaments) functional activities
o Functional instability may result and should be treated
with a course of physical therapy
o Patients may return to unrestricted level of activity
when cutting, running, hopping on affected leg is no
longer painful
o 90% of acute ankle sprains resolve with RICE and early
functional rehab
o Surgery is a reasonable option when adequate trial of
There is pain on direct palpation; there is much swelling of the
nonsurgical management fails to control symptoms
lateral portion of ankle
ANTERIOR CRUCIATE LIGAMENT INJURY
o Most commonly injured – ATFL (weakest of all collateral Epidemiology
ligaments) o ACL is most commonly injured during sports-related
o Anterior drawer test activity with minority occurring in high energy trauma
- Demonstrate anterior talar subluxatIon o 70% of patients hear or feel a pop at time of injury
o Swelling of the knee is noted at 24-48hrs post injury
o Injuries are classified as contact or non contact
- Non contact injuries occurs during cutting or pivoting
o Female athletes is 2-4 times higher risk of ACL injury
compare to males
- Contributing factors
 Biomechanics
 Muscle strength
 Hormonal factors
o Talar tilt stress test  Training
- Demonstrate positive tilt to inversion stress Anatomy
o ACL is composed of 90% type I collagen, 10% type III
collagen (ACL and PCL have the same collagen content)
 Average length: 33 mm
 Average width: 11mm
o Femoral attachment is semicircular area on
posteromedial aspect of lateral femoral condyle
o Tibial attachment is broad, irregular just slightly medial
and anterior to midline and between the intercondylar
eminences of tibia
o Middle geniculate artery is the primary blood supply
o Sulcus sign
o Nerve supply from the posterior articular branch of
- Skin Indentation
posterior tibial nerve

Function of ACL
o Is the primary restraint to anterior tibial translation and
secondary restraint to varus/valgus angulation
Pathoanatomy
o Majority of ACL injuries are complete disruption
o The femoral insertion or midsubstance is usually the
site of disruption
Complete disruption of midsubstance of ACL
Evaluation
o Patient who sustains knee injury during sports activity
followed by sudden swelling of knee
o Note for effusion that is related to hemarthrosis
secondary to bleeding from vascular or torn ligament
o Quadriceps and patellar tendon should be evaluated
o “Lachman test” most useful in diagnosing ACL injury in
acute setting
 A sense of increase movement and lack of solid end
point indicative of ACL injury (positive sign)
Lachman test – one hand is on distal portion of thigh, the o ther
hand on leg. Apply anterior force towards the body of examiner.
Also do on contralateral leg to co mpare movement of knee
 Also you can do ant. drawer test, but Lachman test
is most sensitive or preferred
Imaging
o Radiographs are useful to rule out fracture in acute
setting (cannot diagnose ACL injury alone)
o MRI
 Not required for diagnosis of ACL injury but useful
in assessing for meniscal pathology, subchondral
fracture and other ligamentous injury
Lachman’s test will somehow suffice in the diagnosis
Treatment
- Based on activity of the patient (If athlete, advise
patient to undergo surgical management)
o Non surgical(mostly non-athletes)
 Rehabilitation to strengthen hamstrings and
quadriceps as well as proprioceptive training
 Activity modification
 ACL sports brace
o Surgical
 ACL reconstruction <below (if no reconstruction is
not to be done, treat patient with ACL sports
brace)
ACL reconstruction- uses the hamstring tendon
POSTERIOR CRUCIATE LIGAMENT INJURY
Epidemiology
o 5-20% of all ligamentous injuries of the knee
o Injuries to PCL may be isolated or combined with other
capsuloligamentous injuries of knee
o Isolated PCL injury may be less obvious because
instability is often subtle or even asymptomatic
Anatomy
o Average length is 38mm, average width is 13mm
o Femoral attachment is broad, crescent shaped area
anterolateral on the medial femoral condyle
o Tibial attachment is in central sulcus on posterior aspect
of tibia
o Blood and nerve supply of PCL are similar to ACL but
with a more generous blood supply
Function of PCL
o It is the primary restraint to posterior tibial translation
o secondary restraint to valgus and varus angulation MEDIAL COLLATERAL LIGAMENT INJURY
Epidemiology
Pathoanatomy o Is the most commonly injured ligament of the knee
o Direct blow to proximal aspect of tibia is the most o Concomitant ligamentous injuries
common cause of PCL injury  95% are ACL
o In athletes the mechanism of injury is usually fall onto o MCL is composed of three-layered sleeve of static and
flexed knee with foot plantar flexed dynamic stabilizers
o In high energy trauma, PCL injury is usually associated o Static stabilizers
with other capsuloligamentous structure injuries  Superficial MCL
 Posterior oblique ligament
Evaluation  Deep MCL
o History of injury helps differentiate between high and low
energy trauma Dynamic stabilizer
o PE relies heavily on posterior drawers test (the most
sensitive)

Function of MCL
o Main function is to resist valgus and external rotation loads
Posterior Drawers Test o Superficial MCL is primary restraint to valgus loads
o Posterior oblique, deep MCL and cruciate ligaments are
Imaging secondary restraints to valgus loads
o Plain radiographs are important to rule out fractures and
avulsions and to ensure that knee is not dislocated (but not Evaluation
important to diagnose PCL injury, just r/o fractures) o Knee should be inspected for ecchymosis, localized
o MRI tenderness, presence of effusion
 Helps determined the site of injury and continuity o Abduction stress testing should be performed with knee
of PCL at 0o and 30o (a.k.a. valgus stress test)
o Pathologic laxity is indicated by amount of increased
Treatment medial joint space separation compare to opposite
o Non surgical normal knee
Reserved for isolated PCL injuries o Pathologic laxity (medial joint space grade)
o Surgical  Grade I: 1-4mm
 Indicated for isolated chronic PCL injuries when  Grade II: 5-9mm
there are continued instability symptoms and for  Grade III: >10mm
combined PCL/ capsuloligamentous injuries; o Evaluation of other associated injuries
 PCL reconstruction
 LATERAL COLLATERAL LIGAMENT INJURY
Epidemiology
o LCL injuries are less common than the MCL
o 7-16% of all knee ligament injuries

Anatomy
o Lateral compartment of the knee is supported by
dynamic and static stabilizers
o Dynamic stabilizers consist of :
 biceps femoris
 iliotibial band
 popliteus muscle
 lateral head of gastrocnemius
Abduction Stress Test (Valgus Stress Test of the Knee) o Tatic stabilizer consist of:
 fibular collateral ligament
 popliteus tendon
 arcuate ligament

Imaging Function of LCL

o Plain radiograph o primary restraint to varus stress at 5o & 25o knee flexion
o MRI o The popliteus restricts posterior tibial translation,
 Imaging modality of choice to diagnose external tibial rotation, varus rotation
 Advantage – it identifies the location and extent of injury
Evaluation
Treatment o Adduction stress (a.k.a. varus stress test) is performed
o Non surgical at both 0 and 30o
 Indicated in all grade I and grade II injuries o Isolated laxity at 30o consistent with LCL injury
 Grade III that are stable in extension without o Laxity at both 0 and 30o is seen with additional injury to
associated cruciate injury ACL, PCL
 RICE, rehabilitation and strengthening exercises

o Surgical
 Indicated in isolated grade III injuries with
persistent instability despite rehabilitation
 Acute repair

Varus stress test of knee

Classification of LCL injury

o Grade I: 1-5mm lateral joint space opening
o Grade II: 6-10mm
o Grade III:>10mm
Imaging SHOULDER IMPINGEMENT
o Plain radiograph
o “Rotator Cuff Tendinitis”
o MRI
o Tendinitis/ bursitis/ impingement
o Young and middle aged athletes
Treatment
o Overhead injury
o Non surgical
o Compromised of the space bet the humeral head and
 Indicated for grade I and grade II isolated injuries of LCL
acromial arch
 Limited immobilization with protected weight bearing
o Primary
 Usually due to degenerative changes & spurring
o Surgical
o Secondary
 Complete injuries or avulsion of LCL
 Problem with keeping the humeral head
 Primary repair of LCL
centered in the glenoid fossa
 weakness of the Rotator Cuff muscles
SOFT TISSUE OVERUSE  Symptoms usually activity specific
Pathophysiology
Classification of Impingement
 Tendinosis
o External
 an overuse injury with recalcitrant symptoms of
 Pathology is outside the GH joint and confined to
pain with activity
the subacromial space
 Histologically: a chronic intratendinous
 Compression of the rotator cuff, usually the
degenerative lesion of tendon
supraspinatus by the acromion
 Instead of normal constructive adaptive response
 Slow insidious onset, no history of trauma
of repeated loading, the tendon no longer
respond in positive fashion but starts to o Secondary
accumulate increasing amount of poorly  Problem with keeping the humeral head centered in
organized and dysfunctional matrix (Hallmark of the glenoid fossa during arm movement
tendinosis)  Weakness of the Rotator Cuff
 Occurs most commonly in rotator cuff, patellar
o Subcoracoid/ Stenosis
tendon, achilles tendon, posterior tibialis tendon
 Anterior shoulder pain
Classification of Tendinosis o Internal (Glenoid) Impingement
o Blazina Grading  Posterior shoulder pain in the throwing or overhead
 Grade I- pain that occursonly after activity athlete
 Grade II- pain occurs during activity but does not  Stiffness, slow to warm up
affect performance
Etiology
 Grade III- pain occurs during the activity and affects
o Poor posture
performance such that athlete cannot train and
o Increasing age
perform at desired level
o Poor muscle tone
o Instability of the glenohumeral joint which allows
Treatment
increased translation of the humeral head
- Mostly managed conservatively.
o Degenerative arthritis
o Osteopenia/ osteroporosis
o Non surgical
o Acromion morphologies
 Consist of rest and physical therapy
 Type I- Flat
 Type II- Curved
o Surgical
 Type III- Hooked
 If nonsurgical management fails
 Excise and stimulate healing response Manifestations
 Stimulate bone healing between attachment of o Shoulder pain with shoulder level or overhead activity
tendon and bone o Pain when reaching behind the back
o Pain in the deltoid region or lateral arm
o Shoulder tenderness
o Decreased strength if prolonged
o Loss of range of motion due to pain and disuse
o Pain at night and inability to lie on the affected arm
o Locking sensation with abduction
o Active “palm down” abduction is painful

Neer’s Sign
o Neer's impingement sign is elicited when the patient's
rotator cuff tendons are pinched under the
coracoacromial arch. The testis performed by placing the
arm in forced flexion with the arm fully pronated.
o The scapula should be stabilized during the maneuver to
prevent scapulothoracic motion.
o Pain with this maneuver is a sign of subacromial
impingement.
Empty Can Sign
o Shoulder elevated to 90° in the scapular plane
o Forearms fully pronated (thumb down)
o Examiner instructs the patient to resist downward
pressureon the elbow.
o Pain, weakness in shoulder = Supraspinatus
tendinitis/tear
Full Can sign
o Shoulder elevated to 90° in the scapular plane
o Forearms fully pronated (thumb UP)
o Examiner instructs the patient to resist downward
pressure on the elbow.
o Pain, weakness in shoulder = Supraspinatus
tendinitis/tear
o The supraspinatus is best isolated with the thumb UP (full
can test).
o The empty can test is more likely to cause pain, and
therefore may not show true weakness of the
supraspinatus (due to a tear).
Hawkin’s Sign (aka. “Hawkins-Kennedy test”)
o Examiner stands in front of, or to the side of the patient.
o Involved shoulder is forward flexed to 90°, and the elbow
is flexed to 90°
o Examiner supports the forward flexed arm with one hand,
while internally rotating the shoulder (humerus).
o Shoulder pain = Supraspinatus tendinitis/ impingement
Diagnostics
o Xray
o MRI
o Ultrasound
Treatment Principles
o Restore ROM with proper stretching
o Strengthening of the shoulder-stabilizing musculature
o Pectoral stretches
o Pain relief
o Improve mechanics
o Improve shoulder stability
o Patient education to minimize further trauma
o Patient education on correct posture
o Surgery when all else fails