Sports Medicine: Common Injuries and Conditions

1. Sports Medicine: Common Injuries and Conditions Rodolfo R Navarro, M.D. Christopher McGrew, M.D., CAQSM, FACSM

2. Objectives • Understand the basics of the orthopedic examination • Recognize common injuries and refer students appropriately • Discuss general treatment principles of common injuries • Recognize common head injuries and concussion and refer appropriately • Recognize common complaints of the Back and Hip • Recognize common injuries of the Upper and Lower Extremities and refer appropriately

3. History & Physical • History and Physical are extremely important in the majority of orthopedic injuries! • History should focus on: • Mechanism of injury (MOI) • Location and circumstances • Time of injury • Progression of symptoms • Function of injured body part • Location of pain • Associated symptoms

4. History & Physical • Focus points for an orthopedic exam • Inspection • Deformities, open wounds, bruising, redness • Palpation • Bones, muscles, ligaments • Based on surface anatomy • One joint above and one below • Range of Motion (ROM) • Affected joints, or one joint above and below • Note pain or provocation of symptoms • Motor Function • Affected muscles, or those crossing affect joint(s) • Compare to unaffected side • Special Maneuvers • Dependent on MOI, symptoms, function

5. Treatment Principles • Basic principles of musculoskeletal treatment • Rest • Relative rest with or without weight-bearing • Ice • 10 min on and 10 min off multiple times per day • Compression • ACE bandage is good initially • Elevation • Especially at night • Anti-inflammatories • Ibuprofen/naprosyn (Motrin, Aleve, Advil) • Tylenol is ok too! • Other considerations • Splinting, arm slings, ankle and knee braces

6. Head and Neck

7. Head and Neck • Common injuries and problems • Neck sprains/spasms • Muscular in nature • Lacerations and soft tissue contusions • Of the face or scalp • Concussion • Usually related to athletic activity

8. Head and Neck • Physical Exam focus points • Inspection • Open facial and/or scalp wounds, deformities • Erythema, skin lesions, rashes • Bruising or bleeding, esp. Raccoon’s eye, Battle’s sign, septal hematoma • Palpation • Cranium, mastoid processes, facial bones, cervical spine process • Paraspinal musculature, trapezius • Range of Motion (ROM) • Neck flexion, extension, lateral rotation, lateral bending • Note reproduction of symptoms

9. Head and Neck • Physical Exam focus points • Motor Function • Cranial nerves 2 – 12 (facial muscle deficit, visual acuity, drooping, sensation change, hearing, smell, eye movements) • Neck musculature • Special Maneuvers • Spurling’s (test of cervical root impingment)

10. Head and Neck • Treatment of common injuries • Neck sprains/spasms • RICE, though caution for too much ice • Heat generally better after initial 24-48 hrs • Stretching exercises (ROM) • Gentle massage • Anti-inflammatory medication • Most resolve spontaneously

11. Head and Neck • Treatment of common injuries • Lacerations and soft tissue contusions • Gentle pressure for hemostasis • Ice as necessary • Bandage appropriately • If unable to bandage or control bleeding due to size or depth, refer for immediate evaluation by PCP or ED or urgent care

12. Head and Neck • Treatment of common injuries • Concussion • ABC’s, especially if any amount of LOC • Recommend immediate or next day visit with a physician (PCP/ED/UC) • Advise student and parents on return policies, ie. May miss one or more days of school • Advise student and parent to notify appropriate coach or training staff

13. Head and Neck • Update on Concussion • Current expert consensus is that athletes with a diagnosis of a concussion should undergo a step-wise return to activity • This includes school-work, leisurely reading, texting, playing video games, etc! • 3rd International Conference on Concussion in Sport (Zurich 2008)

14. Head and Neck • Update on Concussion • This is echoed in APS policy regarding a graduated return to activity protocols for concussed students • New Mexico State Law (Senate Bill 1) forbids a coach to allow an athlete to participate in athletic events on the same day as being suspected of having or diagnosed with a concussion • The athlete may not return to activity until released by a licensed health care professional

15. Head and Neck • Need for immediate Emergency Dept referral • Orbital injuries • Craniofacial fractures/instability • Head trauma with extended LOC • Any high-energy or high-velocity head trauma • Suspected spinal cord injury

16. Back & Hip

17. Back & Hip • Common injuries • Muscle sprain of the lower back • Usually multi-factorial in nature • Contusion • Usually related to a fall • Sacroiliac joint dysfunction (Biomechanical dysfunction) • Related to lower extremity mechanics, poor posture, poor core stability, etc.

18. Back & Hip • Physical exam focus points • Inspection • Posture, leg length discrepancies, gait abnormalities • Palpation • Spinous process and paraspinal musculature • Pelvic ring landmarks: iliac crests, SI joints, ASIS, pubic bone, ischialtuberosities • Beware other causes of back/hip pain! • Range of Motion (ROM) • Back: flexion, extension, lateral bend, rotation • Hip: internal and external rotation, flexion, extension, abduction, adduction

19. Back & Hip • Physical exam focus points • Motor Function • Back: no real motor testing • Hip: flexion, extension, abduction, adduction • Special Maneuvers • Straight Leg Raise (for disc/sciatic nerve pathology) • FABER’s (for hip or SI joint pathology) • Log Roll (hip joint pathology)

20. Back & Hip • Treatment of common injuries • Muscle sprain and/or contusion • Relative rest means no heavy lifting, need to stay active! • Ice initially, then heat via heating pad • Stretching exercises (ROM) and massage • Sacroiliac joint dysfunction Typically requires physical therapy • Offer option for foot orthotics, proper footwear, etc

21. Back & Hip • Concerning symptoms or diagnoses • Spinous process tenderness or step-off • Suggesting spondylolysis or spondylolisthesis • Pain radiating from the back down or around the leg • Consider disc pathology/nerve impingement • New-onset or associated saddle anesthesia or incontinence • Acute spinal cord injury (caudaequina syndrome) • Emergency! • Chronic groin pain • Undiagnosed hip dysplasis or femoral head disorder

22. Upper Extremity

23. Upper Extremity • Common chronic issues • Rotator Cuff overuse • Overhead activities and night time pain • Medial/Lateral epicondylitis • Tennis/golf elbow • Multi-directional instability • “Loose ligaments” or history of shoulder dislocation • Carpal tunnel syndrome • Hand/wrist pain, now more common amongst teens

24. Upper Extremity • Common acute issues • Rotator strain or tear • Shoulder pain • Shoulder dislocation or subluxation • Typically will describe a traumatic dislocation • Ligamentous injuries of elbow or hand • From trauma, sporting event, or a fall • Fractures • Wrist and hand, typically from a fall

25. Upper Extremity • Focus points for an orthopedic exam • Inspection • Deformity or asymmetry, swelling • Palpation • Based on surface anatomy • Identify bones and muscles • Range of Motion (ROM) • Limitations and painful ranges • Motor Function • Compare to unaffected side • Special Maneuvers • Dependent on MOI, symptoms, function

26. Upper Extremity • Special maneuvers in the upper extremity: • Shoulder: Neer’s, Hawkins, cross-arm, shift and load, crank, O’Brien’s, Speed’s, Apprehension and Relocation • Elbow: Milking, Ulnar Collateral Ligament stress • Wrist: Tinel’s, Phalen’s

27. Upper Extremity • Treatment of chronic issues • Rotator Cuff syndrome and MDI • Start with anti-inflammatory medication and ice • Medial/Lateral epicondylitis • Anti-inflammatories and elbow strap • Carpal tunnel syndrome • Best initial treatment is a wrist brace, esp. for night

28. Upper Extremity • Treatment of common acute injuries • Rotator strain/tear or dislocation/subluxation • RICE and anti-inflammatory medication • Arm sling for comfort, may remove as soon as possible • Best to begin gentle rotator cuff ROM exercises ASAP • Refer to PCP/sports medicine for PT referral • Ligamentous injuries of elbow or hand • RICE, anti-inflammatory medication • Refer to sports medicine or orthopedic surgeon • Suspected fractures • To PCP/ED/UC

29. Upper Extremity • Special considerations: • Recalcitrant wrist or hand pain • Must consider fracture • Associated numbness or loss of function • Nerve or vascular compromise • Open fractures • Emergency referral

30. Lower Extremity

31. Lower Extremity • Common Chronic issues • IT band syndrome • Lateral hip/thigh pain, sometimes a snapping sensation • Patellofemoral syndrome • Patellar pain, also called anterior knee pain • Medial Tibial Stress Syndrome (shin splints) • Typically an overuse syndrome with inadequate warmup • Plantar fasciitis • Heel/fascia pain worse in am • Tendonitis • Patellar, achilles

32. Lower Extremity • Common acute issues • Knee injuries • Typically, traumatic in nature • Ankle injuries • Typically inversion injuries • Foot injuries • Traumatic blow or twisting MOI

33. Lower Extremity • Physical Exam focus points • Inspection • Deformities, open wounds, bruising, swelling • Monitor for temperature and color change of foot • Palpation • Surface anatomy especially important around knee and ankle • One joint above and one below to rule out fractures • Range of Motion (ROM) • Affected joints, or one joint above and below • Note pain or provocation of symptoms • Knee flexion and extension • Ankle dorsiflexion and plantar flexion, inversion and eversion

34. Lower Extremity • Physical Exam focus points • Motor Function • Same as ROM for knee and ankle • Special Maneuvers • Varus and valgus stress (MCL, LCL stress) • Anterior and Posterior drawer (ACL, PCL stress) • Anterior drawer (tests lateral ankle ligaments) • Talar tilt (lateral ankle ligaments)

35. Lower Extremity • Treatment of common chronic issues • IT band syndrome, PFS, Tendonitis • RICE and anti-inflammatory medication • Will generally require a home exercise program or physical therapy regimen • Non-compliance to rehab can be a detrimental • Shin splints • RICE • Proper warm-up prior to exercise • Proper calf stretching, including straight and bent knee • Plantar fasciitis • Treatment is a gradual process • Orthotics, calf stretching, anti-inflammatory medication

36. Lower Extremity • Treatment of common acute issues • Knee, leg, and ankle injuries • RICE and anti-inflammatory • If immediate or delayed swelling, consider brace • If unable to bear weight, refer immediately to ED/UC • Otherwise, physician assessment ASAP • Foot injuries • Similar to above

37. Take Home Points • Exam: inspection, palpation, ROM, motor function • General Treatment Principles of RICE • Rehabilitation is a stepwise process to returning to participation • For fractures or open injuries, refer to ED immediately • Refer all head injuries and suspected concussions to PCP/ED

38. Questions? • Email: rnavarro@salud.unm.edu