SPORT INJURY – MUSCULOSKELETAL 

PROBLEM
MOHAMMAD ADIB KHUMAIDI, MD- ORTH
 Introduction

 On average, an elite football player suffers from

1.5–7.6 injuries each 1,000 hours of training and
12–35 injuries each 1000 hours of match.
 Several risk factors Injuries depends on level of play
, the exercise load and the standard of training .

Clin Cases Miner Bone Metab . 2012 May-Aug : Musculoskelatal problems in soccer players ;
Current concepts
 Cause of Injury

Cause of injury No. of injuries

Struck by another person 98
Collision with a person/moving object 66
Overuse 40
Over-stretched 33
Rapid acceleration or deceleration 30
Aggravation of a previous injury 23
Awkward landing 17
Fall at ground level 11
Struck by an object 8
Twist or change of direction 7
Fail from height 6
Kicking 2
Running/sprinting 1
Collision with a fixed object 1
Unsure 7
 
Total 350
An examination of the frequency and severity of injuries and incidents at three levels
of professional football. Hawkins RD, Fuller CWBr J Sports Med. 1998 Dec; 32(4):326-
32.
 Location of Injury
Part of the body No. of responses

Head and neck (Head, face, neck, cervical spine) 39

Upper limb (shoulder, clavicula, hand/fingers, elbow,
wrist) 47
Trunk (Pelvis/buttock, abdomen, lumbar spine, thorax and
chest) 36
Lower limb (Hip, groin, thigh, knee, lower leg, ankle, foot
and toes) 228

 
Total 350
 What is an Physicians ?

 The expert in treating the

musculoskeletal system

 The expert in maintaining

musculoskeletal health
 What do we do?

 Diagnose
 Treat
 Medication
 Physical Therapy
 Exercise
 Brace
 Surgery – Orthopaedic Surgeon

 Prevent
 Acute vs. Overuse Injuries

 Acute - sudden trauma such as sprains,

strains, bruises & fractures

 Overuse - series of repeated small

injuries
 Treatment
 R.I.C.E.

 Alter or stop sports activities

 Physical therapy & medication

 Surgery may be warranted

 Ankle Sprain
 Ligament injury

 Ankle pain, tenderness, swelling

 Ankle Sprain
 R.I.C.E.
 Rehabilitation
 Range of motion
 Strengthening
 Flexibility
 Balance
 ACL Injury
 Direct blow to knee
 Non-contact injury,
with foot plant
 Landing on straight
leg
 Making abrupt
stops
 “Back seat” skiing
 ACL Tear
Normal anatomy Hyperextension

Anterior

cruciate
Femur
ligament

Femur slips
Anterior

cruciate

ligament
Patella
tears

Tibia

Fibula

Illustration reproduced with permission from The Body Almanac, Rosemont, IL

American Academy of Orthopaedic Surgeons, 2003
Meniscus Tear

 Helps knee joint

carry weight,
glide, and turn
 Twisting injury

 Football and
other contact
sports
 Rotator Cuff Tears

 Acute injury

 Overuse injury

 Sports and occupations that

involve repetitive overhead
motions
 Overuse Injuries

 Thorough history &

physical exam
 X-rays, MRI might
be needed
 Specialists in
sports medicine
can be particularly
helpful
 Overuse Injuries

 Reduce intensity
 Warm up before
 Ice afterwards
 Work with a coach
 How to Assesment ?

 The parts of the orthopedic evaluation include the

following:
 • History of the injury, including pain assessment •
Physical examination
 􏰇 Observation
􏰇 Palpation
􏰇 Range-of-motion (ROM) and strength testing 􏰇
Special and stress testing
 • Musculoskeletal imaging
 Pain Assesment = PQRST
 P: provocation, precipitating and palliative factors.
 Q: quality/quantity of the pain.
 R: region/radiation.

 S: severity of the pain. .

 T: time.
 Physical Examination – Palpation
 Start the palpation portion of the physical examination by
palpating bones first.

Physical Examination – ROM

 Test the ROM of a joint before strength testing
the muscle groups that surround the joint
( Active and Passive)
 Test ROM

Test for knee-hip flexion Using Goniometer

 Strength – Stress Testing
 Manual Muscle Test (MMT ) the patient
moves a joint through its ROM against
the examiner’s resistance.
 Stress Testing : Valgus/ Varus stress test
 Stress tests are used to evaluate the integrity
of ligaments and joint capsules and are
administered by reproducing the mechanism
of injury. Perform stress tests as soon as
possible after the injury, before swelling
develops.
Special Testing
  Special tests, used to determine whether
nonligamentous structures are injured, produce signs
and symptoms such as tingling, pain, clicking,
popping, snapping, muscle weakness, and muscle
tightness.
 Musculoskeletal imaging
 Plain film radiography

 AP/PA view, Lateral, Oblique and Stress Radiographs

 Bone scan

 A bone scan is the definitive diagnostic technique to detect

a stress fracture

 CT Scan

 MRI

 MRI is the preferred noninvasive imaging technique to

evaluate soft tissue injury.
 Acute Knee Injuries

 Ligament injury
(ACL, MCL)
 Meniscus tear

 Fracture/Bone
bruise
 Patellar
dislocation
 Knee Exam

 Inspection

 Range of motion

 Is there an effusion?

 Joint line tenderness

 Stability
 Inspection

 Erythema

 Cellulitis?

 Septic prepatellar
bursitis
 Range of Motion

 Locked knee?
Effusion
 Is it an effusion?

 Prepatellar bursitis
 Effusion Present

 ACL tear

 Patellar
dislocation
 Fracture or Bone
bruise
 No Effusion

 MCL tear

 Meniscus tear

 Contusion
 Stability Exam: Anterior-
Posterior
 Lachman’s

 ACL Tear
 Stability Exam: Anterior-
Posterior
 Posterior drawer

 PCL tear
 Stability Exam- Medial and
Lateral
 Valgus stress

 MCL tear
 Stability Exam- Medial and
Lateral
 Varus Stress

 LCL tear
 Knee Exam

 Joint line
tenderness
 Meniscal tear?
 Patellar Exam

 Palpate medial and

lateral patellar facets
 Chondromalacia
patella
 Tendon Exam

 Patellar tendon

 Quadriceps
tendon
 Iliotibial band

 Tibial tubercle
 Xray

 May show
fracture
 Growth plate
status
 Often normal
 Xray

 Is it normal?
 MRI

 ACL

 Patellar
Dislocation
 Fracture or Bone
bruise
 MRI

 Quality of MRI
varies
 Radiologists
expertise varies
 ACL Injuries

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

 High intensity
plyometrics,
balance training,
and strengthening
 Neuromuscular
Feedback
 Treatment-ACL Tear-Growth
Plates Closed

 Patellar tendon

 Hamstring

 Allograft
 ACL tear-Growth Plates
Open
 Brace

 Physeal sparing
reconstruction
Patellar Dislocation History

 Twisting injury

 Collision

 May not know

patella dislocated
 Immediate
swelling
 Can’t play
 Patellar Dislocation Exam

 Big effusion

 Patellar
apprehension
 Medial retinacular
pain
 Patellar Dislocation

 Xray
 Patellar Dislocation

 MRI
 Patellar Dislocation

 Loose Body –
Arthroscopy
 Brace?

 Rehab

 Return to play
when comfortable
 Fracture or Bone Bruise
History
 Collision

 Fall

 Non-contact twist
 Fracture or Bone Bruise
Exam
 Effusion

 May or may not

be able to localize
pain
 Inability to bear
weight
 Bone Bruise

 Xray normal

 Diagnose by MRI

 Usually back to
sports in 4-6
weeks
 Fracture

 Xray
 Fracture Treatment

 6-12 weeks to
heal
 Brace?

 Cast

 Surgery
 MCL Tear History

 Valgus injury

 May or may not

have contact
 Pop?

 May keep playing

 May not swell

right away
 MCL Tear Exam

 Medial joint line

pain
 Opening with
valgus stress
 No effusion
 MCL Tear Imaging

 Xray-normal

 MRI
 MCL Tear Treatment

 Brace for 2-6

weeks
 Pass functional
test to play
 Surgery if off tibia
 Meniscal Tear

 History of twisting
injury
 Meniscus Tear Exam

 Swelling may or
may not be
present
 Joint line pain

 Locked knee?
 Meniscal Tear

 Locked knee

 Urgent knee
arthroscopy
 Meniscus Repair

 Non-weight
bearing 6 weeks
 Sports in 4
months
 Meniscus Resection

 Sports in 3 weeks
 Chronic Injuries

 Chondromalacia
patella
 Osgood-Schlatter
Disease
 Stress Fracture

 Osteochondritis
Dissecans
 Chondromalacia Patella

 Poorly localized
anterior knee pain
 Dull, aching pain

 Worse with
jumping, climbing,
squatting
 Exam

 Point tender at medial

patellar facet
 View patellar tracking

 Normal exam-think
about hip
 Chondromalacia Diagnosis

 Xray- usually
normal
 MRI- usually
normal
 Xray pelvis?
 Chondromalacia Patella
Treatment
 Sports menu?

 Brace

 NSAIDS

 Rest

 Physical Therapy

 MRI?
 Osgood-Schlatter Disease

 Overuse injury

 Traction apophysitis
 Osgood-Schlatter Disease

 Jumping sports-
basketball,
volleyball
 Dull, aching pain

 Boys 13-14

 Girls 11-12
 Osgood-Schlatter Disease-
Exam
 Inspection

 Point tender over

tibial tubercle
 Osgood-Schlatter Disease

 Xray
 Osgood-Schlatters
Treatment
 NSAIDS

 Brace

 Relative rest

 Full rest

 Physical therapy

 Knee immobilizer

 Cast
 Osgood-Schlatter Disease

 Goes away when

apophysis fuses
 Stress Fracture History

 Abrupt increase in
activity-must elicit
 Stress Fracture Exam

 May be point
tender
 May be difficult to
localize
 Stress Fracture

 X-ray
 Stress Fracture

 Bone scan
 Stress Fractures

 MRI
 Stress Fracture Treatment

 Rest for 3 months

 Crutches?

 Non-weight
bearing?
 Stress Fracture Healed

 Pain free 2 weeks

 Run 2 miles (30

min) twice per
week
 10% increase per
week
 
Lower Leg and Ankle Injuries
 Shin Splints
 Medial
 Anterior
 Key Causes

 Tight posterior muscles

 Imbalance between the posterior

and anterior muscles
 Running on concrete or other hard
surfaces
 Improper Shoes - inadequate shock
protection
 Overtraining
 Treatment (FYI)

 Rest. The sooner you rest the sooner it will heal.

 Apply ice 10-15 minutes for 2-3x per day in the early
stages when it is very painful.
 Anti inflammatory drugs

 Wear shock absorbing insoles in shoes.

 Maintain fitness with other non weight bearing

exercises.
 Apply heat and use a heat retainer after the initial acute
stage, particularly before training.
 Stress Fractures
 Bone remodeling

 Repetitive stress weakens the bone

 10-20% of injuries to athletes

 Most common locations: tibia, fibula and

metatarsals.
 Tibial and fibular stress fractures can develop from
“shin splints”
 Causes of Stress Fractures

 Training errors

 Abnormal limb length

 Low body weight (< 75% of ideal)

 Eating disorders

 Previous inactivity

 White race

 Female
 Diagnosis (FYI)

 X-ray

 MRI

 CT scans
 Metatarsal Stress Fracture

 CAUSES:

 Decreased density of the bones (eg.

osteoporosis)
 Unusual stress on a metatarsal due
to mal position or another forefoot
deformity (eg. bunion)
 Abnormal foot structure or
mechanics (eg. flatfoot, over
inversion)
 Ankle Sprains
 Most common athletic injury. 25% of all
injuries.
 The risk of ankle sprains varies with the sport
 21-53% basketball, 17-29% soccer, 25% volleyball.

 Ankle sprains account for 10% to 15% of all

lost playing time
 The medial malleolus is shorter than the
lateral mallelous so there is naturally more
inversion than eversion.
 Ankle Sprains
 Greater inversion increases the potential for over-
stretching of the lateral ligaments.
 Most sprains involve the lateral ligaments from
excessive inversion.
 Deltoid ligament is sprained less often (25% of
ankle sprains)
 Of the lateral ligments, the ATFL is sprained the
most often followed by the CFL
 Sprains ocur most often with the foot in plantar
flexion and inversion.
Lateral Collateral Ligament
Ankle Sprains
 Classification of Sprains

 3rd
1st Degree:
Degree
 Stretching
Complete of theATFL,
tear ATFL CFL, and/or PTFL

 little
totalor no of
loss edema
function

 tenderness
significant edema
 maintain function.

 2nd Degree
 Partial tear of the ATFL and/or CFL
 moderate edema
 some function loss
 Ankle Sprains by Grade

Sign/symptom Grade I Grade II Grade III

Tendon No tear Partial tear Complete tear

Loss of functional ability Minimal Some Great

Pain Minimal Moderate Severe

Swelling Minimal Moderate Severe

Ecchymosis Usually not Frequently Yes

Difficulty bearing weight No Usually Almost always

 Treatment (FYI)

 AAFP (see table 3)

 R.I.C.E.

 Ice for 20 minutes on and 20 minutes off for the first

two hours.
 After that, 20 min intervals over the next 48-72 hours,

 Compression wrap with donut or horse shoes to fill in

gaps around malleolus from 24-36 hours; after 48-72
hours contrasts baths with ROM exercises for 4 minutes
in warm and 1 min in ice water.
 Achilles Tendonitists
 Causes
 Rapidly increasing training effort
 Adding hills or stair climbing to
training
 Starting too quickly after a layoff
 Poor footwear
 Excessive pronation
 Tight posterior leg muscles

 If left untreated, it may progress to a

complete rupture.
 Achilles Tendon Rupture
 Most frequently ruptured tendon
 Complete ruptures are due to
eccentric loading during abrupt
stopping, landing from a jump.
 Usually a popping sound is heard
with a complete tear.
 There may or may not be an
obvious gap 2 to 6 cm from the
calcaneus attachment.
 Treatment may or may not
include surgery but both require
immobilized for 3 months.
 Plantar Fasciitis

 The plantar fascia runs from the calcaneus to the

metatarsals.

 This tight band acts like a bow string to maintain the arch of
the foot.

 Plantar fasciitis refers to an inflammation of the plantar

fascia.
 Plantar Fasciitis
 Inflammation is usually
due to repeated trauma
to where the tissue
attaches to the
calcaneus.
 The trauma results in
microscpic tears at the
calcaneus attachment
site.
 This may produce heal
spurs
 Plantar Fasciitis
 Pain is worse in the morning or after a
period of inactivity
 Causes
 High arch
 Excessive pronation
 Footwear (worn out, stiff)
 Increase in intensity
 Turf Toe

 Turf toe is really a bruise or sprain that occurs at the base of

the big toe at the joint called the metatarsal phalangeal joint.
 It usually occurs when the toe is jammed forcibly into the
ground or, more commonly, when the toe is bent backward
too far (hyperextended)
 It causes significant pain and swelling at the base of the big
toe.
 It can be a significant problem because players use the toe
when they run and plant and push off.
Ankle Exercises
 Calf stretch

 Soleus stretch

 Resisted dorsal and

plantar flexion
 Heel raises

 Step-up

 Jump rope
Ankle Exercises
Wobble Boards
 Asking Questions About
Surgery

 Why?

 Alternatives

 Benefits and for how long?

 Asking Questions About
Surgery
 Risks?

 What is procedure called?

 How is it performed?

 Results?
 Asking Questions About
Surgery
 Duration of recovery?
 Assistance at home and how long?
 Disability after surgery?
 Physical therapy?
 Return to normal activity?
 Sports Injuries: Prevention & Treatment

 Thank you for participating today

 Remember, your orthopaedic surgeon can help
get you back in the game
 SOCCER INJURY

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