Sports injuries

Prof. Dr. DENİZ GÜLABİ

Marmara University Faculty of Medicine, Orthopaedics and
Traumatology Department
• The human knee is a complex joint with
• many components making it vulnerable
• to injury. It is the biggest joint of the body.

• It has three bones, femur, tibia , patella.

• The knee joint has 3 articulations, medial tibiofemoral, lateral
tibiofemoral and patellofemoral articulations.
• Medial and lateral side has 3 layers.
• Lateral side
• Layer 1: iliotibial and biceps femoris

• Layer 2: patellar retinaculum

• Layer 3: LCL, ALL, popliteofibular, popliteus, capsule,arcuate and coronary

ligaments.
• Medial side
• Layer 1:Sartorius and hamstring tendons

• Layer 2: semimembanousus, superficial MCL, posterior oblique lig, MPFL

• Layer 3: deep MCL, capsule, coronary ligament

ACL
• ACL(Anterior cruciate ligament)
• Primer function: prevents anterior translation of the tibia relative to the femur.
• Secondary function: prevents varus angulation at full extension.
• Anteromedial bundle: tight in knee flexion and loose in extension
• Posterolateral bundle: tight in extension and loose in flexion. PREVENTS PIVOT-SHIFT rotation of the
knee.
ACL common athletic traumas.
• Common knee problems
• 400.000/years reconstructions.
• More common in female athlets.
• non-contact pivoting injury
• tibia translates anteriorly while knee is in slight flexion and valgus
• Associated conditions
• meniscal tears
• lateral meniscal tears in acute ACL tears, medial in chronic cases.
• felt a "pop"
• pain deep in the knee
• immediate swelling (70%) / hemarthrosis
• Symptoms
• generalized knee pain
• feelings of instability preventing return to sport
• difficulty weightbearing
• Physical examination
• Knee effusion,
• Lack of active knee extension
• ROM painful.
• Lachman is the most SENSITIVE
TEST.
• Pivot shift:knee brought from
extension (anteriorly subluxated) to
flexion (reduced) with valgus and internal
rotation of tibia reduces at 20-30° of
flexion due to IT band tension
ACL injury Radiology
• Radiographs
• AP/LAT/Merchant
• Segond fracture
• MRI: discontinuity of the ACL fibers, sudchondral odema of the lateral
femur condyle and posteromedial tibia, hemarthrosis, empty notch.
• sensitivity and specificity
• 97% and 100% respectively
ACL Treatment
• Depends on activity level, age,
associated injuries.
• Nonoperative treatment
• İnclude decreasing sport activity
level, advising non contact sports.
• Operative treatment
• ACL repair: most popular for
pediatric and avulsion fracture
tibial spine.
• ACL reconstruction. Allogrefts,
autogrefts.
• Arthroscopic ACL reconstruction :most
common orthopaedic surgery
• Single bundle, double bundle: no
difference in clinical outcomes
• Transtibial- anteromedial or far medial
drilling technique: no difference. But
more vertical femoral tunnel in
transtibial technique.
Grefts
• Autogrefts • Some studies have
• Quadriceps:

• Hamstrings: strongest load suggested higher risk of

failure(4000 Newton), hamstring
weakness, parastezia due to the
saphaneous nerve injury, could be
avoided by oblique or horizontal re-rupture associated with
incision
• Bone-patellar tendon-bone: bone to
bone healing, early healing.
• Disadvantages: Anterior knee pain, allograft use, particularly
patella fracture

• Peroneous longus tendon in younger patients.

• ACL tensil strength is
• Native 2200 Newton
• BPTG: 3000 Newton
• Quadrupled (4 layer) hamstring:
4000 Newton
• Allogrefts
• useful in revisions
• no harvest site morbidity
• longer incorporation time
• more expensive than autograft
• risk of disease transmission (HIV is < 1:1.6
million, hepatitis is even greater)
• increased risk of re-rupture in young
athletes.
ACL Surgery Complications
• Intraoperative
• Tunnel mal position
• Femoral posterior Wall blow-out
• Greft rupture
• Infection, septic arthritis(most
common cause stap. Epidermidis).
Multiple Irrigation,debritman and
antibiotics. Retain greft if no macroscopic
visual sign of failure.
• Arthrofibrosis: most common
complication. Lack of pre injury
ROM, so gain full rom before
surgery.
ACL Surgery Complications
• Patella Tendon Rupture
• will see patella alta on the lateral radiograph
• RSD (complex regional pain syndrome)
• Patella fracture
• BPTP and quadriceps grafts w bone block implicated
• most fractures occur 8-12 weeks post-op
• Tunnel osteolysis
• treatment
• observation unless graft laxity and knee instability
• Late osteoarthritis
• related to meniscal integrity
• increased rates noted in patients > age 50 at the time of ACL
reconstruction
• Local nerve irritation
• incidence
• saphenous nerve due to hamstring autograft harvest
• Cyclops lesion
• fibroproliferative tissue blocks extension
• "click" heard at terminal extension
 PCL(Posterior cruciate ligament)
• Primary function: prevents
posterior translation. Secondary
resists varus angulation.
• Medial femur condyle to
posterior tibial sulcus.
• PM bundle: tight in extension,
• AL bundle: TİGHT in
flexion.(short,thick and strong)
• Native PCL strength 2500
Newton
 PCL
• A common dash-board injury.
• Hyperextension injury of the
knee.
• Isolated injury rare
• More common with PLC and
knee dislocation.
• Clinical signs
• Instability
• Pain
• Hemarthrosis
• Posterior sag sign
• Posterior drawer sign
• DIAL TEST
• 10° ER asymmetry at 30° & 90° consistent with PLC and
PCL injury
• > 10° ER asymmetry at 30° only consistent with isolated
PLC injury
PCL EXAMINATION
• posterior sag sign
• patient lies supine with hips and
knees flexed to 90°, examiner
supports ankles and observes for a
posterior shift of the tibia as
compared to the uninvolved knee
• the medial tibial plateau of a
normal knee at rest is 10 mm
anterior to the medial femoral
condyle
• an absent or posteriorly-directed
tibial step-off indicates a positive
sign
• posterior drawer test (at 90° flexion)
• with the knee at 90° of flexion, a
posteriorly-directed force is applied to
the proximal tibia and posterior tibial
translation is quantified
• isolated PCL injuries translate >10-12
mm in neutral rotation and 6-8 mm in
internal rotation
• combined ligamentous injuries
translate >15 mm in neutral rotation
and >10 mm in internal rotation
• most accurate maneuver for
diagnosing PCL injury
• Radiology
• AP/LATERAL Radiographs.

• MRI
 PCL Treatment
• Nonoperative. Low-level activity,
isolated partial tears.
• Operative: combined injury, high
level activity(athletes)
• PCL repair of bony avulsion
fractures or reconstruction
Chronic PCL deficiency results
in patellofemoral and medial
compartment ARTHROSİS.
POSTEROLATERAL CORNER
• Resists ER and posterior
translation
• LCL
• Popliteus tendon
• Popliteofibular ligament
• Fabellofibular ligament
• Capsule
• Iliotibial band
• Arcuate ligament
 PLC(Posterolateral corner)
• Lateral instability
• With ACL OR PCL.(PCL more
common)
• Traumatic.
• Associated injuries
common peroneal nerve
(15-29%)
vascular injury
• DIAL test and MRI for diagnosis.
• Posterolateral drawer test
• Reverse pivot-shift test.
 PLC Treatment
• Nonsurgical: partial tears, and isolated lesions.

• Surgical: Acute: time to 3 weeks: REPAİR

• Chronic: Reconstruction.
Medial Collateral Ligament
• Resists valgus stress Works with
ACL .
• Medial epicondyle to proksimal
medial periosteum, and medial
meniscus.
• Two parts
• Superficial: main stabilizator(30
degree flexion)
• Deep: especially stabilize knee at
full extension
Strength 4000 Newton.
 MCL
• Traumatic valgus stress injury
• Medial side tenderness, pain,
ecchymosis and valgus
instability
• Associated injry: ACL,
Meniscus(medial common)
• Commonly treat with bracing.
• calcification at the medial
femoral insertion site
(Pellegrini-Stieda Syndrome
 MCL Treatment
• Commonly conservative

• Surgical:>10 mm medial sided

opening in full extension
• Repair
• Reconst.
Posteromedial corner
• MCL
• Posterior oblique ligament
• Semimembanosus tendon
• Oblique popliteal ligament
• Posterior capsule
Medial patellofemoral ligament
• Primer resistant to lateral dislocation of the
patella from 0 to 30 degree flexion of the
knee.
• İnsertion
• Femur: shottle line: a line through the
posterior cortex of the femur and a
perpendicular line to the first line from the
posterior corner of the bulmenstat line.
• Patella:fan-like structure inserting at junction
between proximal-middle thirds of
superomedial border of patella.
• More commonly tears from the femoral
attachment.
PATELLAR INSTABILITY
 • RADIOLOGY
• HEMARTHROSIS

• MRI. help further rule out

• MEDİAL SIDE TENDERNESS.
suspected loose bodies
• osteochondral lesion and/or
bone bruising
• medial patellar facet (most
common)
• lateral femoral condyle
• Nonoperative
• NSAIDS, activity
modification, and physical
therapy
• indications
• mainstay of treatment for first
time patellar dislocator
• without any loose bodies or
intraarticular damage
• OPERATİVE
• Arthroscopic debridement
(removal of loose body) vs
Repair with or without
stabilization
• MPFL REPAIR
• MPFL RECONSTRUCTION.
Anterolateral Ligament
• Prevents rotational instability
• İnsertion
• Femur: Lateral epicondyle

• Tibia: midway between Gerdy's

tubercle and head of fibula
• Segond's fracture (associated with
ACL rupture) is avulsion fracture of
ALL
 CARTILAGE INJURY
• Cartilage injuries are often caused by trauma, contact sports, repetitive weight bearing, and age
• related degeneration. Articular cartilage is very important for the preservation and normal function of
the joints. In the knee, cartilage is responsible for providing a smooth protective layer covering the
femur, tibia and the patella undersurface, as well as serving as a shock absorber for the knee.

• LOOSE BODY(LOCKING, CATCHING)

 CARTILAGE INJURY

• SWELLING(RECURRANT)
• PAIN
• LOCKING
• PEDIATRIC OCD(Most common
in posterolateral side of the
medial condyle 70%)
 •Outerbridge Arthroscopic Grading System
•Grade 0 •Normal cartilage
•Softening and swelling
•Grade I (noted with tactile feedback
with probe)
•Partial-thickness defect with
surface fissures (do not
•Grade II
reach subchondral bone or
exceed 1.5 cm in diameter)
•Deep fissures at the level of
•Grade III subchondral bone with a
diameter more than 1.5 cm
•Grade IV •Exposed subchondral bone
MRI(Radiology)
 CARTILAGE(TREATMENT)
• Nonoperative
• rest, NSAIDs, physiotherapy, weight
loss
• Operative
• debridement/chondroplasty vs.
reconstruction techniques
• MICROFRACTURE(LESS THAN 2cm square)
• Mosaicoplasty(osteochondral autogreft
2-4 cm square)
• Autologous chondrocyte implantation (ACI)(more
than 4 cm)
 MENISCUS
• The meniscus are small “c” shaped structures in the knee between the femur and tibia that act like
cartilage and “shock absorbers” for the joint. The function of the meniscus is to distribute load and
protect the articular cartilage of the knee from early degeneration. Each knee has two menisci- the
medial meniscus and the lateral meniscus.
HISTOLOGY

• Fibroelastic cartilage
• Collagen, proteoglycan, glycoprotein,
• % 65-70 water
• % 90 Type 1 collagen
• 2 type fibers
• Radial fibers
• Surround Sircumferential
• Longitudinal ( sircumferential fibers )
• Most fibers
• spread hoop stress through the joint.
Meniscus Anatomy

• Medial Meniscus
• C type
• Posterior horn > Anterior Horn
• Attachment wh MCL so to capsule.

• Lateral Meniscus
• oval
• Anterior Horn = Posterior Horn
• more mobile, weak attachment to capsule.
MENISCUS FUNCTION

• CARRY AND ABSORB LOAD

• TRANSFER LOAD.
• Cartilage lubrication and nutrition
• Absorb shock.
• Stability
Medial menisküs posterior horn
Main seconder stabilator of
the tibia for anterior
translation.
 • Injury mechanism
• Rotation in knee flexion
• youth – Sports injury
• Older age – Degeneration
• teanagers – Discoid meniscus are more prone to
Meniscus injury
• Medial Meniscus ruptures > Lateral Meniscus
lesions ruptures (x3)
• Acute ACL ruptures – Lateral Meniscus
ruptures
• Degenerative ruptures – Medial Meniscus
posterior horn.
Clinical signs (symptons)

• Pain
• Mechanical symptoms (locking and clicking),
especially with squatting
• Effusion(swelling)
Physical assessment

• Pain at joint line.

• joint line tenderness is the most
sensitive physical examination
finding
• Effusion
• Provocative Tests
❖ McMurray Test
❖ Apley Test
❖ Thessaly Test
❖ Rıdvan Ege Test
McMurray Test
• Specifity and sensitivity % 70
• Supine position
• At joint line
• Palpabl pop,
• click
• Pain
• Medial Meniscus
Flexion – External Rotation
Valgus Stress - Extension
• Lateral Meniscus
Flexion - İnternal Rotation
Varus Stress- Extension
APLEY TESTİ
• Distraction – compresion Test
• Sensitivity %60, Spesifity % 70
• Prone position, knee at 90 degree flexion
• Increased rotation in distraction means
❖ Ligament injury
• Decrease in rotation and increase in pain
❖ Meniscus injury
 •standing at 20 degrees of knee flexion on the affected
limb, the patient twists with knee external and internal
rotation with positive test being discomfort or clicking.

Thessaly Test
Rıdvan Ege Test
• Sensitivity %65, Spesifity %85
• Apply at standing position.
• Knees are in full extension
• At maximum external and internal rotation
• Pain
• Pop sign or clicking
 Görüntüleme
• ı yırtık Direk grafi
• Gençlerde akut menisküs yaralanmalarında normal görünüm
• Meniskal kalsifikasyonlar – Artropatilerde
• Diskoid Menisküs
• MRG
• %85-95 sensitivite, %81-93 spesifite
• Yüksek yanlış pozitiflik – gereksiz cerrahiler
• Yırtık Bulguları
• T2 sekanslarda hiperintensite
• Parameniskal kistler – Horizontal Yırtıklar
• Çift PCL bulgusu – Kova Sapı Yırtık
• Çift anterior horn bulgusu – Kova sapı yırtık
Meniscus ruptures
•location
•red zone (outer third, vascularized)
•red-white zone (middle third)
•white zone (inner third, avascular)
•position (anterior, middle, posterior third, root)
•size
•pattern
•vertical/longitudinal
•common, especially with ACL tears
•repair when peripheral
•bucket handle
•vertical tear which may displace into the notch
•oblique/flap/parrot beak
•may cause mechanical locking symptoms
•radial
•horizontal
•more common in older population
•may be associated with meniscal cysts
•complex
•root
•functionally equivalent to a total meniscectomy
•lateral root tears associated with ACL tears
•medial root tears associated with chondral injuries
 Meniscus Ruptures
•
• Vertical longitudinal
Vertical/Longitudinal Obligue Degenerative Transvers (Radial Horizontal
• Oblique
• Degenerative
• Radial
• Horizontal
• Bucket handle
• complex
• Nonoperative
• rest, NSAIDS, rehabilitation
• indications
• indicated as first line
treatment for degenerative
tears
• outcomes
• improvement in knee function
following physical therapy
 SURGERY
• partial meniscectomy
• indications
• tears not amenable to repair
(complex, degenerative, radial
tear patterns)
• repair failure >2 times
• meniscal repair
• indications
• best candidate for repair is a tear with the following
characteristics
• peripheral in the red-red zone (vascularized region)
• lower rim width correlates with the ability of a meniscal
repair to heal
• rim width is the distance from the tear to the peripheral
meniscocapsular junction (better blood supply).
• vertical and longitudinal tear
• rather than radial, horizontal or degenerative tear
• bucket handle meniscus tear
• 1-4 cm in length
• root tear
• acute repair combined with ACL reconstruction
•
 Meniscus sutures
• İnside-outside :
- %80 success – golden
technique
- Vertical matrix is the BEST
• Outside-inside
• All inside
MOST COMMON FOOT AND ANKLE SPORTS
INJURIES
• ATFL, CFL RUPTURES(%90)
• physical exam shows drawer
laxity in plantar flexion(ATFL)
• physical exam shows drawer
laxity in dorsiflexion(CFL)
• ACHILLES TENDON RUPTURE
• (THOMPSON TEST)
• 5. METATARS FRACTURE
Epidemiology Ankle Injuries
• Most common musculoskeletal
injury
• 85% are sprains
• lateral injuries
• **ATFL (Anterior Talofibular
Ligament)
Risk Factors

• Cutting and jumping

sports
• Basketball
• Soccer
• Tennis
• Volleyball
• Prior ankle injury
 Anatomy
• Lateral (fibular
collateral) ligament
complex
• Anterior talofibular
ligament ATFL
(weakest)
• Posterior talofibular
ligament PTFL
(strongest)
• Calcaneofibular
ligament CF
 Anatomy
• Syndesmotic ligament
complex
• Axial, rotational, &
translational stability
• Four ligaments:
• Anterior tibiofibular
ligament
• Posterior tibiofibular
ligament
• Transverse tibiofibular
ligament
• Interosseous ligament
Physical Exam - Observation
• Inspection / Observation
• Obvious deformity?
• Ecchymosis?
• Swelling?
• Gait?
Physical Exam - Special Tests
• Thompson test

• Anterior drawer

• Talar tilt

• Reverse talar tilt

• Squeeze test

• External rotation test

 Anterior Drawer Test
• Tests integrity of ATFL

• Foot in neutral / slightly

plantarflexed positions

• A few millimeters of translation

is normal

• Compare to contralateral side

• Positive:
• Laxity
Talar Tilt
• Tests integrity of CFL (> ATFL)

• Performed with foot neutral

/ plantarflexed
• Neutral 🡪 CFL
• Plantarflexed 🡪 + ATFL

• Apply varus stress

• Compare to contralateral
side
Anatomic Classification of Lateral
Ankle Sprains
• Grade I sprain
– Stretching of ATFL & CFL

• Grade II sprain
– Partial tear of ATFL &
stretching of CFL

• Grade III sprain

– Rupture of ATFL & CFL
– Partial tear of PTFL +/- partial
tear of tibiofibular ligaments
When to Cast or Immobilize?

• Fracture
• Avulsion or Salter Harris

• ? Grade III sprain

• Inability to bear weight

with negative films

• Syndesmotic injury
 ACHILLES TENDON RUPTURES

• occur due to sudden dorsiflexion of a plantarflexed foot.

• rupture usually occurs 4-6 cm above the calcaneal insertion in

hypovascular region
• Thompson test
• lack of plantar flexion when calf is squeezed
Achilles Tendon Rupture
• Treatment
• Surgery or a cast (sedentary individuals, wound problems, high-risk surgical
patients)
• Prevention
• Stretching and proper care of any tendonitis
ZONE 1: PSEUDO JONES, ZONE 2: JONES
FRACTURE