SPORT INJURY

Dr. Meiky Fredianto Sp.OT

SPORT MEDICINE
Injury prevention
Diagnosis

Treatment and

Rehabilitation
SPORT MEDICINE TEAM
Orthopaedic surgeon
Family physician
Physiotherapist/ physical therapist
Sport physician
Massage therapist
Radiologist
Podiatrist
Dietitian/ nutritionist
Psychologist
Sport trainer/ athletic trainer
Other professionals
Coach
Fitness adviser
THE CHALLENGES OF MANAGEMENT
Secret success sport medicine broad view
patient and the problem, narrow view short term
amelioration of symptom but will ultimately lead
to failure
Two main challenges
Diagnosis problem and cause
Treatment
SPORT INJURIES
Physical activity activity-related injury
Acute injury vs overuse injury

Depend mechanism of injury and onset of

symptoms
ACUTE INJURIES
Extrinsic causes vs intrinsic causes
Classified according particular site injured and
type of injury :
Bone
Articular cartilage
Joint
Ligament
Muscle
Tendon
Bursa
Nerve
skin
BONE
Fracture
Periosteal contusion
ARTICULAR CARTILAGE
Osteochondral/ chondral fractures
Minor osteochondral injury
JOINT
Dislocation
subluxation
LIGAMENT
Sprain/ tear (grades I-III)
MUSCLE
Strain/ tear (grades I-III)
Contusion

Cramp

Acute compartment syndrome

TENDON
Tear
Complete
Partial
BURSA
Traumatic bursitis
NERVE
Neuropraxia
SKIN
Laceration
Abrasion

Puncture wound
OVERUSE INJURIES
Three distinct challenges
Diagnosis
Treatment
Understanding why the injury occured

Cause
Extrinsic
Intrinsic
EXTRINSIC CAUSE
Training errors
Surfaces

Shoes

Equipment

Environmental

Condition

Psychological factors

Inadequate nutrition
INTRINSIC FACTORS
Malalignment
Leg length discrepancy

Muscle imbalance

Muscle weakness

Lack of flexibility

Sex, size, body composition

Others
BONE
Stress fracture
Bone strain, stress reaction

Osteitis, periostitis

Apophysitis
ARTICULAR CARTILAGE
Chondropathy
Softening
Fibrillation
Fissuring
Chondromalacia
JOINT
Synovitis
Osteoarthritis
LIGAMENT
Inflammation
MUSCLE
Chronic compartment syndrome
Delayed onset muscle soreness

Focal tissue thickening/ fibrosis

TENDON
Tendinopathy
Paratenonitis
Tenosynovitis
Tendinosis
Tendinitis
BURSA
Bursitis
NERVE
Entrapment
Minor nerve injury/ irritation

Adverse neural tension

SKIN
Blister
Callus
KNEE
 A diarthrodial joint that allows simultaneous
rotation and translation
Overview of Knee Ligament Function
Ligament Primary function Secondary function
Anterior Cruciate Ligament Resists anterolateral displacement of Resists varus displacement at 0
(ACL) the tibia on the femur degrees of flexion
Posterior Cruciate Ligament Resists posterior tibial displacement, Resists varus displacement at 0
(PCL) especially at 90 degrees of flexion degrees of flexion
Lateral Collateral Ligament Resists varus displacement at 30 Resists posterolateral rotatory
(LCL) degrees of flexion displacement with flexion that is
less than approximately 50
degrees
Popliteofibular Ligament / Resists posterolateral rotation of the Resists varus angulation
Posterior Lateral Corner (PLC) tibia on the femur andposterior displacement of
the tibia on the femur
Medial Collateral Ligament Resists valgus angulation Works in concert with ACL to
(MCL) provide restraint
to axial rotation
ANTERIOR CRUCIATE LIGAMENT
(ACL)
Function
prevents anterior translation of the tibia relative to
the femur
Anatomy
intrasynovial
origin
lateral femoral condyle
insertion
broad and irregular
anterior and between the intercondylar eminences of the

tibia
two bundles
tight in extension, loose in flexion
POSTERIOR CRUCIATE LIGAMENT
(PCL)
Function
prevents posterior translation of the tibia relative to
the femur
Anatomy
origin
medial femoral condyle
insertion
tibial sulcus
two bundles
LATERAL COLATERAL LIGAMENT
(LCL)
Function
to provide support to varus angulation
works in concert with MCL to provide restraint to axial
rotation
also known as "Fibular Collateral Ligament".
Anatomy
origin
on lateral femoral condyle posterior and superior to insertion
of popliteus
insertion
on the fibula anterior to the popliteofibular ligament on the
fibula
capsule's most distal extent is just posterior to the fibula
structure
cord-like
MEDIAL COLATERAL LIGAMENT
(MCL)
Function
to provide restraint to valgus angulation
works in concert with ACL to provide restraint to
axial rotation
Anatomy
origin
MFC to medial tibia extending down several centimeters
structure
two components
superficial portion (tibial collateral ligament)

deep portion (medial capsular ligament)

HISTORY AND PHYSICAL EXAM
OF THE KNEE
History Physical Exam
ACL Usually non-contact Lachman positive
Landed awkwardly Pivot shift positive
Felt "pop" Large hemarthrosis
Immediate swelling
PCL Struck dashboard Posterior sag sign
Fall with PF foot Posterior drawer (at 90 flexion)
Posterior pain Quad active test
MCL Blow to outside of knee Valgus instability
Medial pain
LCL Varus injury Varus instability
Lateral pain
PLC Lateral and posterior pain Dial test positive (at 30 flexion)
Usually combined with other
ligament injuries
Menisc Mechanical symptoms (catching, Joint line tenderness
us locking) McMurray positive
Pain at joint line
Delayed swelling
Patella Patellar apprehension
Fall with DF foot
Tender over MPFL
May feel 2 "pops"
Effusion
Swelling
Patellar crepitus
Anterior pain
Pain with active compression test
Pain with stairs
Increased Q-angle
LOOK
Skin
scars
trauma
erythema
Swelling
Muscle atrophy
normal quadriceps circumference
10 cm (VMO)
15 cm (quadriceps)
Asymmetry
Gait
antalgia
stride length
muscle weakness
Standing limb alignment
neutral, varus, valgus
FEEL
Joint line tenderness
Tenderness over soft tissue structures
pes anserine bursae
patellar tendon
iliotibial band

Point of maximal tenderness

Effusion
patella balloting
milking
MOVE
Active and passive
flexion/extension normal range
10 extension (recurvatum) to 130 flexion
rotation varies with flexion
in full extension, there is minimal rotation
at 90 flexion, 45 ER and 30 IR

abduction/adduction
in full extension, essentially 0
at 30 flexion, a few degrees of passive motion possible
NEUROVASCULAR EXAM
Sensation
medial thigh - obturator
anterior thigh - femoral
posterolateral calf - sciatic
dorsal foot - peroneal
plantar foot - tibial
Motor
thigh adduction - obturator
knee extension - femoral
knee flexion - sciatic
toe extension - peroneal
toe flexion - tibial
Vascular
pulses
popliteal
dorsalis pedis
posterior tibial
ankle-brachial index
ABI < 0.9 is abnormal
KNEE IMAGING
X ray
MRI

Ultrasound
MENISCUS
Function :
Force transmission
the meniscus functions to optimize force transmission
across the knee. It does this by
increasing congruency
shock-absorption
transmits 50% weight-bearing load in extension, 85% in flexion
Stability
the meniscus deepens tibial surface and acts as secondary
stabilizer
medial meniscus
lateral meniscus
the menisci become primary stabilizers in the ACL-
deficient knee
Composition
Made of fibroelastic cartilage
interlacing network of collagen, proteoglycan,
glycoproteins, and cellular elements
composed of 65-75% water

Collagen
90 % Type I collagen
Fibers
composed of two types of fibers
radial
longitudinal (circumferential)
Anatomy
Gross Shape
medial meniscus
C-shaped with triangular cross section
lateral meniscus
is more circular (the horns are closer together and approximate the ACL)
covers a larger portion of the articular surface
Attachment
transverse (intermeniscal) ligament
coronary ligaments
meniscofemoral ligament
Blood supply
medial inferior genicular artery
lateral inferior genicular artery
Innervation
peripheral two-thirds innervated by Type I and II nerve endings
posterior horns have highest concentration of mechanoreceptors
Injury & Healing potential
Tears in peripheral 25% red zone
can heal via fibrocartilage scar formation
Tears of central 75%
have limited or no intrinsic healing ability
MENISCAL PATHOLOGY
Epidemiology
most common indication for knee surgery
higher risk in ACL deficient knees

Location
medial tears
more common than lateral tears
degenerative tears in older patients usually occur in

the posterior horn medial meniscus

lateral tears
more common in acute ACL tears
Classification
Descriptive classification
location
red zone (outer third, vascularized)
red-white zone (middle third)

white zone (inner third, avascular)

size
pattern
vertical/longitudinal
bucket handle

oblique/flap/parrot beak

radial

horizontal

complex
Presentation
Symptoms
pain localizing to medial or lateral side
mechanical symptoms (locking and clicking)
delayed or intermittent swelling
Exam
joint line tenderness is the most sensitive physical
examination finding
effusion
provocative tests
McMurray's test
flex the knee and place a hand on medial side of knee,
externally rotate the leg and bring the knee into extension.
a palpable pop or click is a positive test and can correlate
with a medial meniscus tear
Imaging
Radiographs
Should be normal in young patients with an acute
meniscal injury
Meniscal calcifications may be seen in crystalline
arthropathy (ex. CPPD)
MRI
indications
MRI is most sensitive diagnostic test, but also has a high
false positive rate
findings
parameniscal cyst indicates the presence of a meniscal tear
may see "double PCL" sign that indicates a bucket-handle
meniscal tear
 Non-operative
rest, NSAIDS, rehabilitation
indications
indicated as first line of treatment for degenerative tears

Operative
partial meniscectomy
meniscal repair
meniscal transplantation
total meniscectomy
ACHILLES TENDON RUPTURE
Acute rupture of the achilles tendon
often misdiagnosed as an ankle sprain
may be missed in up to 25%
Epidemiology
incidence
18:100,000 per year
demographics
more common in men
most common in ages 30-40
risk factors
episodic athletes, "weekend warrior"
flouroquinolone antibiotics
steroid injections
The condition is often associated with poor muscle strength and
flexibility
Failure to warm up and stretch before sport
Previous injury or tendinitis
 Mechanism
usually traumatic injury during a sporting event
may occur with
sudden forced plantar flexion
violent dorsiflexion in a plantar flexed foot

Pathoanatomy
rupture usually occurs 4-6 cm above the calcaneal
insertion in hypovascular region
ANATOMY
Achilles tendon
largest tendon in body
formed by the confluence of
soleus muscle tendon
medial and lateral gastrocnemius tendons

blood supply from posterior tibial artery

PRESENTATION
History
patient usually reports a "pop"
Symptoms
weakness and difficulty walking
pain in heel
Physical exam
inspection
increased resting ankle dorsiflexion in prone position with
knees bent
calf atrophy may be apparent in chronic cases
palpation
palpable gap
motion
weakness to ankle plantar flexion
provocative test
Thompson test
lack of plantar flexion when calf is squeezed
IMAGING
Radiographs
indications
used to rule out other pathology

Ultrasound
indications
may be useful to determine complete vs. partial ruptures
MRI
indications
equivocal physical exam findings
chronic ruptures

findings
will show acute rupture with retracted tendon edges
TREATMENT
Nonoperative
functional bracing/casting in resting equinus
indications
acute injuries with surgeon or patient preference for non-

operative management
sedentary patient

medically frail patients

Operative
end-to-end achilles tendon repair
percutaneous achilles tendon repair
reconstruction with VY advancement
flexor hallucis longus transfer +/- VY advancement of
gastrocnemius
ACHILLES TENDONITIS
Mechanism
overuse
imbalance of dorsiflexors and plantar flexors
poor tendon blood supply
genetic predisposition
fluoroquinolone antibiotics
inflammatory arthropathy
Pathophysiology
theorized to be due to abnormal vascularity 2 to 6 cm
proximal to Achilles insertion in response to
repetitive microscopic tearing of the tendon
 Presentation
symptoms
pain, swelling, warmth
worse symptoms with activity

difficulty running

physical exam
tendon thickening and tenderness 2 to 6 cm proximal to
Achilles insertion
pain throughout entire range of motion
 Imaging
MRI
disorganized tissue will show up as intrasubstance
intermediate signal intensity
thickened tendon

chronic rupture will show a hypoechoic region between

tendon ends
 Treatment
nonoperative
activity modification, shoe wear modification, therapy, NSAIDs
indications

first line of treatment

techniques
therapy
physical therapy with eccentric training modalities (iontophoresis,
phonophoresis, and ultrasound)
shoewearheel lifts
cast or removable boot (severe disease)
outcomes
nonoperative management is 65% to 90% successful

operative
percutaneous tenotomies
open excision of degenerative tendon with tubularization
tendon transfer (FHL, FDL, or PB)
LOW ANKLE SPRAIN
Epidemiology
ankle sprains are the most common reason for missed
athletic participation
most common injury in dancers
Associated injuries include
osteochondral defects
peroneal tendon injuries
subtle cavovarus foot
deltoid ligament injury (isolated deltoid ligament
injuries are very rare)
fractures
5th metatarsal base
anterior process of calcaneus

lateral or posterior process of the talus

PRESENTATION
Symptoms
pain with weight bearing
recurrent instability
catching or popping sensation may occur following
recurrent sprains
Physical exam
focal tenderness and swelling over involved
ligament(s)
anterior drawer test
possible laxity with anterior drawer and eversion/inversion
stress testing
IMAGING
Radiographs
indications for radiographs with an ankle injury include (Ottawa
ankle rules)
inability to bear weight
medial or lateral malleolus point tenderness
5MT base tenderness
navicular tenderness
radiographic views to obtain
standard ankle series (weight bearing)
AP
lateral

mortise

ER rotation stress view

varus stress view
MRI
indications
consider MRI if pain persists for 8 weeks following sprain

useful to evaluate
peroneal tendon pathology
osteochondral injury
TREATMENT
Nonoperative
RICE, elastic wrap to minimize swelling, followed by therapy
indications
Grade I, II, and III injuries

technique
may require short period (approx. 1 week) of weight-bearing
immobilization in a walking boot or walking cast, but early mobilization
facilitates a better recovery
therapy
once swelling and pain have subsided and patient has full range of motion
begin neuromuscular training with a focus on peroneal muscles strength
and proprioception training
a functional brace that controls inversion and eversion is typically used
during the strengthening period and used as prophylactic treatment
during high risk activities thereafter
early functional rehabilitation allows for quickest return to physical
activity
Operative
anatomic reconstruction vs. tendon transfer with tenodesis
arthroscopy