1. Mikey Bengzon, MD, MBAH 30 November 2010
Sports Injuries
Mikey Bengzon, MD, MBAH
30 November 2010

2. Specific Learning Objectives:
Enumerate and define common acute and chronic orthopedic Sports injuries.
Describe the anatomy and physiology of musculoskeletal structures.
Review the ligamentous anatomy of the knee.
Analyze the pathology of Orthopedic sports injuries.
Enumerate the methods of treatment of Orthopedic sports injuries.

6. Sports Injuries Acute injuries Chronic injuries Ankle sprain
Muscle Strain
Contusion
rupture/dislocations
Chronic injuries
Tendinitis
Stress Fractures
Osgood Schlatter Disease
Sever’s disease

8. Orthopedic Sports Injuries
S - Onset: Acute vs. Chronic;
MOI: Direct vs. Failure
O - Location: Long bone vs. Periarticular; Structure: Osseous vs. Soft tissue
A – Osseous or non osseous, Location
P - ?

9. Contusion Blunt injuries
Intra: Within the compartment; more painful; swelling lasts longer; no obvious hematoma
Inter muscular: less painful; swelling resolves sooner; obvious hematoma
Grade 1 – 3 (tightness)

10. Stress(?) Fracture Incomplete fracture Overuse -> Fatigue
Force transfer from muscle to bone
Rx: Rest vs IF

11. Osgood Schlatter Disease

12. Sever’s Disease Inflammation of the growth plate 8-13 year olds
Overuse injury in running sports
Rx. Rest, control of inflammation

13. Mallet finger

14. Rotator Cuff Tears Supraspinatus Infraspinatus Teres Minor
Subscapularis

15. Yield/ Failure
Toe Region
Linear Region
Stress
Strain

16. Types of Muscle Contraction
Concentric – Joint moves with a load and the muscle shortens (biceps contract)
Eccentric – results in muscle lengthening while controlling a load during joint motion (biceps in elbow extension)
Isometric – fixed load with no joint motion (quadriceps sets)
Isokinetic – variable load with constant velocity (exercise bike)
Isotonic contraction - tension rises and the skeletal muscle shortens

17. Yield/ Failure
Toe Region
Linear Region
Stress
Strain

18. 2 types of Skeletal muscles
Type I – Slow twitch, more for endurance and aerobic bc of the presence of mitochondria and myoglobulin
Type II – fast twitch, for rapid generation of power but anaerobic so less able to sustain prolonged contraction
Type IIA vs Type IIB

19. Factors affecting muscle properties
Strength training – High force, low repetition: leads to an increase in muscle strength; increase muscle fiber size leads to an increase in contractile proteins
Endurance training – (low tension, high repetition): Increases capillary density & mitochondria concentration resulting in VO2 max and improved fatigue resistance
MHR = 220 – Age
Increase VO2 max, HR must increase to 65-85% of MHR

20. Tendons Connects muscle to bone
Collagen are more parallel and larger compared to ligaments
Relatively avascular
2 tendinous areas:
Musculotendinous
Osteotendinous

21. Functions of Tendons
Length of tendon allows muscle belly to be at a distance from the joint
Transmits force between muscle and bone
Tensile stresses are high
Conservation of muscular energy during locomotion/ energy storage capacity
Satisfies kinematical and damping requirements

22. Mechanical Properties of Tendons
Greater cross - sectional area
Larger loads can be applied prior to failure
Increased tissue strength
Increased stiffness
Longer tissue fibers
Greater fiber elongation before failure
Decreased tissue stiffness
Unaltered tissue strength

23. Strain Pertains to muscles Overexertion Grade 1 strength maintained
Grade 2 – decrease strength
Grade 3 – loss of strength
Treatment – Similar to sprains
Definiton

24. Yield/ Failure
Toe Region
Linear Region
Stress
Strain

25. Tendinitis
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26. Lateral Epicondylitis
Tennis elbow
Tendinitis at the common extensor origin in the elbow
Elbow and wrist extension

27. Ligaments vs. Tendons Ligaments Tendons % Collagen Less More
% Ground Substance
more
less
Organization
More random
Organized
Orientation
Weaving pattern
Long axis direction

28. LIGAMENT TENDON COMPONENT Cellular Materials: Fibroblasts 20%
Extracellular:
Water
60-80%
Solids
20-40%
Collagen
70-80%
Slightly higher
Type I
90%
95-99%
Type III
10%
1-5%
Ground substance
20-30%
Slightly less
Elastin
Up to 2X Collagen
Scarce

29. Dislocations/Subluxations

30. Mechanical Behavior of ligaments
Yield/ Failure
Toe Region
Linear Region
Stress
Strain

31. Sprain Pertains to ligaments Ankle, knee & finger Children vs adults
Grade 1- fxn maintained
Grade 2 – partial weight bearing
Grade 3 – unstable
Treatment: depends on severity
Definition of sprain
Types of sprain

32. Ligaments
Soft connective tissue composed of densely packed collagen fibers
Mechanical properties depend on function and location
Fibroblasts
Extracellular matrix

33. Ligaments Functions: Holds skeleton together
Transmit load bone to bone
Provides stability at joints
Limits freedom of movement
Prevents excessive motion by being a static restraint
Occasionally acts as a positional bend/strain sensor
Mediate motions bw opposing fibrocartilage surfaces

34. Ligaments No molecular bonds between fascicles
Free to slide relative to each other
Parallel or Branching/interwoven
Collateral vs Cruciates
Smaller diameter than tendons
Simon, SR. Orthopaedic Basic Science. Ohio: American Academy of Orthopaedic Surgeons; 1994.

35. Crimping: orientation of collagen in ligaments
Allows elongation of fibers before tensile stresses are experienced

36. Viscoelastic Response
Viscous – resists strain; Elastic – returns to original state
Dependent on
Magnitude of load
Duration of load
Prior loading
Affected by movement of water
Resistance to compressive forces due to water trapped in proteoglycans
Contributes to sustained or cyclic responses to stress
Types of responses
Creep
Stress relaxation
Hysteresis

37. Creep Time dependent elongation when subjected to a constant stress
Tendons: in an isometric contraction, the tendon will lengthen slightly and more muscle fibers will be recruited in order to maintain the position of the limb
Ligaments: Joints will loosen with time, decreasing the possibility of injury
Ex. Maintaining posterior pressure of the knee in extension

38. Stress - Relaxation
Time dependent decrease in applied stress required to maintain a constant elongation
Tendons: in an isotonic contraction, the stress will decrease with time
Ligaments: joints will loosen with time decreasing the possibility of injury
Ex. Biceps curls x 2 reps

39. Hysteresis Energy lost within the tissue between loading and unloading
Response of tissue becomes more repeatable
Subsequent use of the same force results in greater deformation

40. Knee Injuries

42. Knee Injuries Medial Collateral Ligament (MCL) strains
Anterior Cruciate Ligament (ACL) tears
Meniscal Tears

43. Examination of the Knee
Bone
Soft tissue
Ligaments

45. Anterior Cruciate Ligament
Located between the femur & tibia at the center of the knee
Origin: Medial Surface of the Lateral Femoral condyle
Insertion: anterior tibial plateau
Intracapsular; extrasynovial
2 bundles: AM & PL*
+ Lachman’s & Anterior
drawer’s test

49. ACL
Anterior Drawer’s test
Lachman’s test
Pivot Shift

50. KT 2000

51. ACL MRI

54. Posterior Cruciate ligament
Origin: Medial Femoral Condyle
Insertion: Posterior Cortical surface of the tibia in the sagittal midline
Covered by synovium (intimately associated with the posterior capsule)
Blood supply from the middle geniculate artery
+ sag sign,
Posterior drawer’s test

55. Medial Collateral Ligament
Primary stabilizer to valgus
Origin: MFC at the adductor tubercle
Insertion: Medial aspect of the proximal tibia
Superficial and Deep layer
+ Valgus Stress test

56. Lateral Collateral Ligament
Origin: Lateral Femoral condyle
Insertion: fibular head
Resists Varus stress

60. Meniscal tear

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63. Stages of Healing
Inflammation
Fibrosis
regeneration
Weeks

64. R.I.C.E. REST – avoid painful movements but use as tolerated
Ice – 20 minutes at a time x hours
Compression
Elevation
Address main pathology
More info on RICE

65. Issues in Treatment Temperature:
Negative Effects of Ice, Dr. Ho, University of Hawaii – Decreases blood flow and metabolism
1980 AOS & AJSM – nerve palsies
Motion – immobilization affects overall health of the joint (scar tissue, cartilage necrosis, ligament weaknening)
Medications
NSAIDS: inhibit fibroblastic growth processes

66. Post Surgery
Range of Motion
Strengthening
Endurance