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DAVID C. KORONKIEWICZ, D.O. IU GOSHEN ORTHOPEDICS & SPORTS MEDICINE SPORTS INJURIES Indiana Osteopathic Association 32 nd Annual Winter Update December.

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Presentation on theme: "DAVID C. KORONKIEWICZ, D.O. IU GOSHEN ORTHOPEDICS & SPORTS MEDICINE SPORTS INJURIES Indiana Osteopathic Association 32 nd Annual Winter Update December."— Presentation transcript:

1 DAVID C. KORONKIEWICZ, D.O. IU GOSHEN ORTHOPEDICS & SPORTS MEDICINE SPORTS INJURIES Indiana Osteopathic Association 32 nd Annual Winter Update December 6,2013

2 Sports Injuries-Outline Overview Types of injuries Prevention Specific injuries

3 Statistics In the United States, about 30 million children and teens participate in some form of organized sports, and about 3.5 million injuries occur each year. Participation in high school athletics is increasing, with more than 7.3 million high school students participating annually * High school athletes account for an estimated 2 million injuries and 500,000 doctor visits and 30,000 hospitalizations each year. ** *(Source: National Federation of State High School Associations) **JS Powell, KD Barber Foss, Injury patterns in selected high school sports: a review of the seasons. J Athl Train. 34:

4 Injuries Most sports and recreational injuries are the results of: sprains (ligamentous injuries), strains (musculotendinous injuries),and contusions. Knee injuries (meniscal & ACL), bursitis, fractures, and dislocations are all commonly seen.

5 Top 15 Sports/Recreational Injuries* Basketball: 512,213 Bicycling: 485,669 Football: 418,260 Soccer: 174,686 Baseball: 155,898 Skateboards: 112,544 Trampolines: 108,029 Softball: 106,884 Swimming/Diving: 82,354 Horseback riding: 73,576 Weightlifting: 65,716 Volleyball: 52,091 Golf: 47,360 Roller skating: 35,003 Wrestling: 33,734 *Treated in ER based on data from the US Consumer Produce Safety Commission on Injuries

6 Acute vs. Overuse Injuries Acute - sudden trauma causing sprains, strains, bruises & fractures Overuse - series of repeated small injuries resulting in pain

7 Causes of Overuse Injuries Increasing activity too quickly Running or jumping on hard surfaces Training vigorously without adequate rest Poorly functioning equipment Improper techniques Working through pain Lack of stretching/strengthening

8 When to See the Physician Decreased ability to play Inability to play Limp, loss of motion or swelling Visible deformity Severe pain

9 Injury Classifications Sprains: injuries to ligaments Strains: injuries to muscles, tendons or the junction between the two Contusions: common bruises or contusions are the most frequent sports injury. Fractures & Dislocations: fractures and dislocations represent two categories of injuries involving either bones or joints of the body

10 Preventing Sports Injuries Know and abide by rules Wear appropriate protective gear Know how to use equipment Never play through pain

11 Skilled sport specific instruction Year round conditioning Preventing Sports Injuries

12 Make Sure Your Athletes Always Warm Up First! Preventing Sports Injuries

13 Break a sweat Marching Walk in place Jumping jacks Mimic the sport you are about to do WARM UP

14 Breathe slowly and deeply Relax into the stretch Should not feel pain Avoid bouncing Hold stretch 30 seconds Stretch both sides Stretching Stretching:

15 Injuries MOST COMMON Strains & Sprains THIS NOT THAT

16 Strain Overstretching of a muscle Caused by overexertion or by lifting Frequent site is the Back

17 Strains Signs & Symptoms Localized swelling Cramping Inflammation Loss of function Pain General weakness Discoloration Prevention Proper warm-up Stretch Proper mechanics Proper cool-down/ stretch Proper nutrition & hydration

18 Strain First aid treatment Rest the muscle affected while providing support Cold applications initially to reduce swelling Warm wet applications applied later because warmth relaxes the muscles Obtain medical help for severe strains and back injuries that dont improve

19 Sprain Injury to the tissues surrounding a joint Usually occurs when part is forced beyond its normal range of motion Ligaments, tendons and other issues are stretched or torn Common sites for sprains are the ankles and wrists Signs and symptoms Swelling, pain and discoloration Impaired motion at times

20 Sprain First aid for sprain R est and limited or no movement of the affected part I ce to reduce swelling and pain C ompression with elastic bandage to control swelling E levation of the affected part Obtain medical help if swelling is severe or if there is any question of a fracture

21 Contusion Bruise Sudden traumatic blow to body (severe compression force) Usually injury to blood vessels under skin Speed of healing depends on tissue damage and internal bleeding Hematoma formation is caused by a pooling of blood and fluid in a tissue

22 Tendon Injuries Tears commonly at muscle belly, musculotendinous junction, or bony attachment Tendonitis: inflammation of tendon- muscle attachments, tendons, or both

23 Tendonitis Signs & Symptoms Pain & inflammation Worse with movement Treatment RICE NSAIDs-Advil, Aleve Ultrasound therapy Rehabilitation Prevention Slowly increase intensity & type of exercise Dont try to do more than ready for Proper warm-up & stretch

24 Skeletal Injuries Subluxation Occurs when bone displaces and partially separates Dislocation Excessive force that causes the ends of the bone to separate and usually remain apart requiring them to be put back together

25 Fracture Fracture is a break or loss of structural continuity in a bone Wrist/Forearm Fractures

26 Increase youth participation Immature bones and muscles Insufficient rest after an injury Poor training or conditioning Specialization in just one sport Year-round participation Why are Injuries on the Rise?

27 Children & Sports Youths of same age can differ tremendously in size and physical maturity.

28 Injuries in Female Athletes

29 Common injuries in women/girls include: Anterior cruciate ligament (ACL) injuries Patellofemoral pain syndrome Stress fractures

30 ACL Girls Soccer – 1 torn ACL for every 6,500 times a girl competes or practices Boys Football – 1 torn ACL for every 9,800 times a guy competes or practices Girls Basketball – 1 torn ACL for every 11,000 times a girl competes or practices

31 ACL Injury Direct blow to knee Non-contact injury, with foot plant Landing on straight leg Making abrupt stops

32 ACL

33 ACL Injuries 400,000 reconstructions per year in the US Females 4 times more likely to tear ACL with non-contact injury

34 ACL Women have an increased predisposition to ACL injury Many theories, but no one proven definitive cause

35 ACL Injuries Intrinsic factors: Joint laxity Hormones Limb alignment Ligament size Intercondylar notch size Extrinsic factors: Conditioning Experience Skill Strength Muscle recruitment patterns Landing techniques

36 ACL Female athletes rely more on their quads and calf muscle than their hamstrings Jumping & landing techniques in women are also different

37 MRI ACL NormalTorn-ACL

38 ACL- What to do? Prevention Learn how to fall, jump and to cut Plyometric training Reduce landing forces and improve strength ratios (quadriceps:hamstrings) Increase hamstring activation

39 Hip Pain in Runner 18 year old female runner with 1 month of anterior groin/inguinal pain Pain worse with weight bearing Over past week she has developed night pain What are the possibilities?

40 Differential Dx. Torn adductor muscle Avulsion of adductor or sartorius muscle Pubic ramus fracture Femoral neck fracture Femoral shaft fracture SI joint subluxation Ruptured iliopsoas bursa

41 Physical Exam Swelling noted in groin and high proximal femur Pain with all attempts at motion, especially internal rotation Distal pulses 2+ No distal sensory deficits

42 Do You Need X-rays?

43 AP Hip X-ray

44 MRI

45 Femoral Neck Stress Fracture Groin pain in runner or jumper- dont ignore Female triad at increased risk as well as those with an increase in training and postmenopausal women Need to know which side the stress fracture is on (compression vs tension side) Plain films often negative Get MRI

46 Treatment If stress fracture by x-ray or further imaging Compression side 12 weeks to heal +/- NWB Tension side Ortho consult/surgery Femoral neck fracture- surgery Cross train Proper nutrition and calories

47 Complications if Missed Stress to complete fracture Avascular necrosis Chronic pain End of career

48 Patellofemoral Pain Syndrome Anterior knee pain Probably more than one etiology Chondromalacia (softening of cartilage) Malalignment of patella

49 Patellofemoral Pain Syndrome

50 Clinical Features and Exam: Reports of anterior knee pain Pain with climbing stairs and/or sitting for prolonged periods of time Pressure on the kneecap during bending and straightening of the knee may elicit cracking and popping with discomfort Abnormal kneecap alignment Genetic Acquired

51 Patellofemoral Pain Syndrome Other causes Muscle imbalances Foot type (either flat or high arched feet) Shoes Overuse Treatment includes: decreasing activity, correct alignment issues, physical therapy for strengthening, bracing or taping

52 Patellar Dislocation Planted foot with twisting of the body around the knee (similar to ACL) Kneecap off to the side Very painful

53 Patellar Dislocation MRI

54 Patellar Dislocation Loose Body – Arthroscopy Brace? Rehab Return to play when comfortable

55 Osgood-Schlatter Disease Jumping sports- basketball, volleyball Dull, aching pain below the knee Bump may be present Boys Girls 9-13

56 Osgood-Schlatter Disease Overuse injury Traction apophysitis (growth plate)

57 Osgood-Schlatter Disease Overuse injury Traction apophysitis (growth plate)

58 Osgood-Schlatter Treatme nt NSAIDS Ice Brace Relative rest Full rest Physical therapy Knee immobilizer Cast

59 Osgood-Schlatter Disease Pain usually goes away after the growth plate closes The bump will remain

60 Meniscus Tear History of twisting injury to the knee Symptoms Pain Giving way Locking Clicking Swelling

61 Meniscus Tear Commonly injured Torn cartilage

62 Meniscus Two C shaped cushions between the thigh and shin bone Helps knee joint carry weight, glide, and turn

63 Stress Fracture Small incomplete break in bone due to: Overuse Poor muscle balance Lack of flexibility Weakness in soft tissue Biomechanical problems Malnutrition Stresses on body are greater than body can compensate Symptoms Pain Tenderness after activity No or little pain in AM, but pain returns after activity

64 Stress Fractures Chronic, overuse injury Most common in weight bearing bones Feet, tibia, femoral neck Seen commonly in Female Athlete Triad (eating disorders, amenorrhea (lack of menstrual periods) & osteoporosis(low bone mass) Diagnosis by x-ray, bone scan or MRI Treatment is rest, address biomechanical issues-- -some fxs are surgical (e.g. femoral neck)

65 Return to Running Progression of functional activity Very structured, all timed Pain & symptoms are to guide progression Can have frequent setbacks

66 Return to Running Phase I: Walking 30 minutes, aggressive, pain free Phase II: Plyometric Routine Hopping, 470 foot contacts Phase III: Walk/Jog progression 5 minute/1 minute to 2 minute/4minute Phase IV: Timed Running Schedule Intermediate & Advanced

67 Achilles Tendon Rupture History Acute pain in the back of the ankle with contraction, no antecedent history of calf or heal pain Average age 35 Steroids, fluorquinolones, and chronic overuse may predispose to rupture Pathology Rupture occurs 3-4 cm above the Achilles insertion in a watershed area

68 Achilles Tendon Rupture Physical Exam Tenderness over achilles tendon Palpable defect Positive Thompsons test Needle test- needle inserted midline 10cm proximal to the superior aspect of the calcaneous moves towards the foot when the calf is squeezed No evidence to support routine use of MRI, U/S, or Xray

69 Surgical repair – Younger active patients Nonoperative treatment – Older sedentary patients – Patients with increased risk of soft tissue complications IDDM Smokers Vascular disease BMI > 30 Achilles Tendon Ruptures

70 Nonoperative treatment – Weaker tendon – Higher risk re-rupture – Slower return to sport – No surgical morbidity – Lower cost

71 Indications of Non-Operative Versus Operative Treatment Indications: Non-Operative Tx may be indicated for older patients with minimally displaced ruptures Non-Operative may be indicated for patients who are at an increased operative risk due to age or medical problems Note that younger patients w/ expectations of participating in sports such as basketball may not be good candidates for non operative Tx

72 Management of Non-Operative Tx Short leg cast strategy (SLC) SLC is applied w/ ankle in plantarflexion Cast is brought out of equinus over 8-10 weeks Walking is allowed (in the cast) at 4-6 weeks Alternatively, consider using functional brace starting in 45 degrees of flexion Following casting, a 2 cm heel lift is worn for an additional 2-4 months Long leg cast (LLC) Initial LLC in gravity equinus for 6 weeks, followed by short leg cast for 4 weeks

73 Achilles Tendon Rupture Non-Operative Resistance exercises started at 8 weeks Return to sports in 4 – 6 months May take 12 months to regain maximal plantarflexion power

74 Clinical Evidence to Support Nonoperative Treatment Benefits: no wound complications, no scar, decreased patient cost. Disadvantage: up to 39% re-rupture rate, increased patient dissatisfaction, decreased power, strength and endurance. Nistor and later Gilles and Chalmers- non-operative treatment preferred because: No hospitalizations No wound complications No difference in functional strength Gillies and Chalmers- 80% vs. 84.3% return of strength compared to unaffected side, non-op and operative, respectively Wills, 775 patients the overall complication rate of surgically treated Achilles tendon ruptures was 20%. skin necrosis, wound infection, sural neuromas, adhesions of the scar to the skin, and the usual anesthesia risks

75 Achilles Tendon Ruptures Surgical repair – Superior tendon strength – Lower risk re-rupture (1-3%) – Quicker return to sport – Surgical morbidity Infection Dehiscence Superficial nerve injury – Increased cost

76 Achilles Tendon Rupture Surgical treatment Preferred for athletes Medial incision avoids the sural nerve Percutaneous vs. Open treatments described Isolate the paratenon as a separate layer

77 Conclusion The current preferred treatment in young and other wise healthy patients is surgical repair Conservative treatment remains an acceptable alternative in older, sick or sedentary patients who have fewer physical demands with limited functional and athletic goals

78 Lisfranc Injury Lisfranc injuries may represent 1% of all orthopedic trauma, but 20% are missed on initial presentation Inability to WB, mid-foot pain, weight bearing x- rays are key

79 Do You Need X-rays ?

80 X-rays

81 Treatment RICE Bulky Jones dressing or posterior splint NWB on crutches Frequent neurovascular checks Refer to Ortho

82 Complications if Missed Chronic pain Arthritis Inability to run or jump Acute compartment syndrome

83 Wrestling Bursitis Shoulder injuries Auricular hematomas

84 Bursitis Knee Elbow

85 Shoulder Injuries Dislocation Separation

86 Shoulder Dislocation

87 AC Separation

88 Surgical Repair Shoulder dislocation AC joint repair

89 Ear Injury Irritation of the ears can occur to the point that permanent deformity can ensue. Some of these injuries may include: Cauliflower-ear Lacerations Ruptured eardrum To avoid these problems, special ear guards should be routinely worn.

90 Auricular Hematoma Cauliflower ear Wrestling % of all injuries Direct trauma or abrasion Head or knee Incidence reduced with headgear 16% (51% to 35%) Only 5% of coaches require headgear at practice

91 In addition to protecting the teeth, mouth guard absorbs shock and helps to prevent concussions. Mouth Guards

92 Correctly fitted mouth guard prevents the majority of dental trauma. Fit should be: Tight fit Be comfortable Unrestricted breathing Should not impede speech during competition. Fit is best when retained on the upper jaw and projects backward only as far as the last molar. Composed of a flexible, resilient material.

93 Cheerleading Journal of Pediatrics 10/21/12 Academy of Pediatrics Position Paper Sport Designation Better conditioning Availability of trainers Better coaching Undergo Physicals Sport Designation Better conditioning Availability of trainers Better coaching Undergo Physicals 37,000 ER visits last year

94 Injuries

95 Ankle Sprain Ligament injury Ankle pain, tenderness, swelling

96 Ankle Sprain

97 Treatment R.I.C.E. – Rest, Ice, Compression and Elevation Modify athletic activity Rehabilitation ROM, strengthening, flexibility, balance Cooperation and communication between patient, parents, coaches and physician

98 Wrist Injuries

99 Ganglion Cysts

100 Mallet Finger

101 Finger Dislocations A dislocation occurs when the normally opposed bones of a joint are separated so that the joint congruity is lost.

102 Jammed Finger Diagnosis only by exclusion. Jamming force on extended PIP joint. Diffuse swelling with painful movement. R/O fracture, tendon injury Exact pathology is not known.

103 Jammed Finger Bruising of the articular surfaces, secondary effusion and resultant edematous soft tissue swelling most likely sequence of events. Prolong morbidity. Up to 9 months of soreness. Permanent residual thickening about the joint.

104 Plantar Fasciitis Painful heel Heel Spur Microtears of plantar fascia

105 Plantar Fasciitis Heel cups Tape heel, arch Orthotics

106 Plantar Fasciitis Stretch (calf and plantar fascia) Against wall or curb On a step Plantar fascia stretch

107 Plantar Fasciitis Massage may be helpful Warm up well before stretching Ice heel, minutes Anti-inflammatories Night splint

108 Plantar Fasciitis Wear good, supporting shoes Arch support Avoid activities that cause heel pain See your physician if pain persists

109 Shoulder Overuse Injuries Tendonitis Overhand sports - pitching, serving: (tennis,volleyball), swimming Weight lifting Use proper technique, good supervision

110 Overuse Injuries Reduce Intensity Warm up before Ice afterwards Work with coaches 10% Rule Dont Increase Activity by More Than 10% Per Week

111 Conclusion Year round conditioning Cross train Warm up/ stretch Use proper equipment Listen to your body Seek medical care if pain continues

112 Thank you THE END

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