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
Spiderman Rehab
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:
1. Medial Tibial Stress Syndrome
2. Chronic compartment syndrome
3. Tibial stress 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.
Knee Sports injuries
• Aims
o To have a working knowledge of knee anatomy to explain common injuries to
patients
o To appropriately refer knee meniscal injuries
o Be aware of patella tendonitis
• Objectives
o Be able to draw a schematic diagram of a knee
o To be able to diagnose meniscal injuries and know the difference between
sports injuries and fragility tears
o Know Diagnosis and treatment for patella tendonitis.
Anatomy
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:
o Haemarthrosis
o Arthroscopy without imaging
o 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?
• http://www.youtube.com/watch?v=hqNC3sXzJII&fe
ature=relmfu
• http://www.youtube.com/watch?v=ul09qA4hJQg&
feature=related
Patella tendinitis
• One of the commonest tendinopathies
• Rest, Ice, NSAIDS, Stretches before future exercise
• Eccentric loading exercises
• Refer to physio.
Question Session