Musculoskeletal in sports

medicine
John Butarbutar

Sports Medicine
Etiology, diagnosis, treatment and
prevention of disorders and injuries
of athletes, as well as with the ideal
methods of athletic training

Salter, Textbookof Disorders and

Injuries of teh
musculoskeletalSystem

Muscle
disorder &
injury

Hamstring strain
Composed of
biceps femoris
semitendinosus
semimembrano
sus

History
A noncontact injury , either acute or
insidious onset. Strain injuries
frequently are seen in athletes who
run, jump, and kick. Avulsion injuries
are seen in patients who participate in
water-skiing, dancing, weight lifting,
and ice-skating. The patient may
report a popping or tearing sensation.

Physical
Tenderness over the site of injury
Ecchymosis
A palpable defect may be felt with
severe strains, but swelling and the
deep location of the muscle may
obscure this finding in the acute stage.
Pain with passive extension of the
knee and with resisted knee flexion

Imaging
Radiographs can rule out an avulsion
injury from the ischial tuberosity
When a confirmation or grading of a
hamstring strain is necessary,
magnetic resonance imaging (MRI) is
the most sensitive test

3 grades of severity of hamstring

injuries.
First-degree strain is the result of
stretching of the musculotendinous unit
and involves tearing of only a few
muscle or tendon fibers.
Second-degree injury refers to a more
severe muscle tear without complete
disruption of the musculotendinous unit.
Third-degree injury refers to a complete
tear of the musculotendinous unit.
The American Medical Association (AMA)

treatment
Protection, rest, ice, immobilisation ,
gradual mobilization, muscle
stretching and strengthening
Surgery

Test

Etiology
Strength
Flexibility
Warm up
Fatique

Worrell, T.W., & Perrin, D.H. (1992)Journal of

Orthopaedic and Sports Physical Therapy, 16, 12-18.

Motor units

2- The Mechanism of Force Generation in Muscle

Tissue

Fiber Type Comparison

Shortening
Speed
Energy System
Size
Force
Production
Aerobic
Capacity
Anaerobic
Capacity
Fatigability

Type I
slow

Type IIa
fast

Type IIb
fast

oxidative

glycolytic

small
low

oxidative,
glycolytic
large
high

high

medium

low

low

medium

high

low

medium

high

large
high

Greatest Risk
a) 2-joint muscles
b) muscles that limit ROM
c) muscles used eccentrically

Which consequences do you

expect ?
Myasthenia gravis: autoimmune disease where
antibodies against the Ach receptors are
produced
Muscular dystrophy: some proteins forming the
muscle fibers are abnormal.
Curare binds to the Ach receptor without
activating them. What are the effect of curare on
the skeletal muscle?
The botulism toxin prevents the release of the
neurotransmitter into the synapse.
Nerve gas inhibits acetylcholinesterase present
in the synapse.

 Rigor mortis: why does the body

stiffen shortly after death?
How do muscles become fatique
after several contraction ?
What are the different effects
between high intensity and long
sustained exercise to the muscle ?

Tendon
disorder
and injury

Achilles Tendon Injury

Common site for injury and rupture
Symptoms include posterior heel
pain with stiffness
The tendon is thickened
Neovascularization might be involved
in the pain mechanism

mechanism
Pushing off with the weight bearing
forefoot while extending the knee (53%)
Sudden unexpected dorsiflexion of the
ankle (17%)
Violent dorsiflexion of a plantar flexed
foot (10%)

Arner and Lindholm ,Acta Chir

Scandinavia ,1959

Examination
Diffuse edema, bruise, palpable gap,
2-6 cm proximal to the insertion
Calf squeeze test
Knee flexion test

presentation
Sudden pain in the affected leg (feels
like struck or kicked )
Audible snap
Weakness of affected ankle

imaging
MRI and US are methods of choice
Treatment
Rest, acitivy modification,
NSAIDs,physical therapy, surgical
debridement, eccentric muscle
training, bracing, heel inserts(Tasto
et al 2003, Koenig et al 2004)

treatment
Conservative with cast or splint
surgery

Pain mechanism
Overuse and degeneration
Local hypoxia, micro trauma,
impaired wound healing may
contribute
Pathology linked to degradation of
collagen and hypercellularity
Tendon contains no inflammatory
cell

Tendon healing
Occurs through extrinsic and intrinsic
processes
Divided into 3 phases
Inflammation (Day 0-7)
Repair (Day 3-60)
Organisation and remodelling (Day 28-180)

Organisation (28-180 days)

Final stability acquired during this phase
by the normal physiological use of the
tendon
Accompanied by cross linking between
fibrils further increasing tendon tensile
strength
Complete regeneration never achieved
Defect remains hypercellular
Thinner collagen fibrils

 What is pain mechanism in rotator

cuff tendinosis?
How do you examine lateral
epicondylitis, de quervainn, biceps
tendonitis ?

Ligament disorders and

injury

Anterior cruciate ligament

rupture

Injury Mechanism
50-70% are
noncontact injuries
These usually
involve planting,
cutting and jumping
This also commonly
involves imbalances
of body weight and
malalignment of
body position

History
Noncontact
injury
Audible pop
Immediate
hemarthrosis

Examination
Hemarthrosis
Lachman Test
Done at 20-30
degrees of knee
flexion

Pivot shift Test

Drawer test

Lachman Test

1+ 0-5 mm of anterior
displacement - sometimes with
an end point
2+ 5-10 mm of anterior
displacement - with no end
point
3+ 10 mm of anterior
displacement - with no end
point
Comparison to other side is
important

Xray Findings
Tibial Spine
Avulsion Fracture
8%

Radiology. 1993
Jun;187(3):821-5.

MRI Findings
any discontinuity or signal change in the ligament is
indicative of ACL tear;

indirect signs of ACL tear:

always look for signs of additional injury (meniscal tear,
PCL tear, LCL tear);

Pivot shift injury: combination of signal changes in lateral

femoral condyle and posteror lateral tibial plateau:

abnormal slope of ACL

MRI Findings

MRI Findings

Treatment Options
Surgery: Reconstruction
Restores stability, prevents further injury

Conservative Treatment
older patients w/ isolated ligament
injury who are willing to moderate their
activity willfind non-operative treatment
to be satisfactory in the majority of
cases (over 80%)

Ligaments
Made of dense fibrous tissue with the
fibers in roughly parallel lines in the
direction of functional need
In most cases pliable but inelastic
Bind bones to bones
Supply passive support and guidance
to joints

Ligaments
May be so integrated into the joint
capsule that they are
indistinguishable as separate
structures
Reinforce joint stability
Generally loose enough to allow free
joint movement within a desirable
range
Designed to prevent movement in a
range which would be damaging

Ligaments
Blood supply
Poor in the ligament itself
Ligaments depend on diffusion to supply
inner fibers with nutrients
Vascular damage during injury can be
particularly bad for the healing of
ligaments
Blood flow is facilitated by passive
movements after injury or surgery

Ligament Stress-Strain
Curve
failure

yield point

toe

elastic

plastic

Sensory Receptors in
Ligaments
May supply feedback to muscle
tissue
Allow muscles to be recruited to
assist in joint stability

Failure Mechanisms
Ligamentous Failure The ligament itself
fails
Characteristic of fast loading rates

Bone Avulsion The bone itself fractures

or fails beneath the junction of ligament
and bone
Characteristic of slow loading rates

Failure at the Ligament-Bone Junction

The least common type of failure