Sports Injuries
Department of Orthopedics&Traumatology
Assoc. Prof. Dr. Deniz Aydın
Aim
• Definiton of the sport injuries
• Anatomic review
• Explaining the diagnostic physical examination
and diagnostic modalities
• Investigation of the treatment methods
• Different anatomic regions will be evaluated
seperately
2
Knee
• Anatomy &biomechanics
• Meniscal injuries
• Ligament injuries
• Osteochondral lesions
• Synovial lesions
• Patellofemoral disorders
3
Knee joint
• Sliding and rolling movements
• Flexion and extension movements combined
with internal and external rotation
• Ligaments
– ACL
– PCL
– MCL
– LCL
4
Anterior cruciate ligament
• Travels between tibial intercondylar
spine to posteromedial surface of
lateral femoral condyle
• 30 mm length and 11 mm radius
• Anteromedial band : resist anterior
translation
• Posterolateral band : resist rotation
• 90% type 1 and 10% type 3 collagen
5
Posterior cruciate ligament
• Anterolateral surface of medial femoral
condyle to tibial sulcus
• 38 mm length and 13 mm radius
• Anterolateral and posteromedial bundle
6
Collateral ligaments
• MCL : Superficial and deep parts
• LCL: lateral femoral condyle to
fibular head
• Posteromedial corner
• Posterolateral corner
7
Meniscus
• Crescent shape fibrocartilage tissue
• Cross sectional area is triangle shaped
• Type 1 collagen is most common
• Peripheral part of meniscus is vascularised
and central part is avascularised
• MM C shaped, LM circular
• Function: deepening articular surface,
providing stability, lubrication and joint
nutrition
• Intermeniscal ligament (connects both
meniscus anteriorly)
• Peripheral attachment – coronal ligaments
• Lateral meniscus is more mobile
8
Meniscal injuries
• Meniscal tears are the most common reasons of knee
surgery
• MM tears are 3 times more common than LM
• ACL injuries – LM tears are more common
• Meniscal tear or menisectomy – osteoarthritis rate
increase
• Traumatic meniscal tear – younger (sport injury)
• Degenerative tears – older
• High healing potential – young age, peripheral 1/3 tear,
acute tear, tears repaired with ACL
9
Meniscal tear classification
10
Meniscal injuries
• Mechanism
– Young: twisting or pivoting
– Older: minor trauma
• Signs and Sx
– Swelling
– Catching
– Giving way
– Locking
• Diagnosis
– History & P.E.
– Xray- exclude other pathologies
– MRI
– Diagnostic arthroscopy
11
Meniscal injuries - Treatment
• Asymptomatic – conservative treatment
• Mechanical symptoms – surgery
– Partial menisectomy : irrepairable tears
– Meniscal repair: Peripheric, longitudinal tears in
young people with acute tears
• especially when ACL reconstruction will be done
together
• Technique: all inside, inside out, outside in, open
12
Meniscal injuries
• Meniscal cyst
– Most commonly associated
with horizontal tears of lateral
meniscus
– Popliteal (baker ) cyst
• Discoid meniscus
– Lateral meniscus
– Partial, total, wrisberg
– Popping knee (mechanic
symptoms)
13
• Meniscus transplantation
– Controversial
– Young patient
– Total menisectomy
– Symptomatic chondropathy
14
Ligament injuries
• ACL
• PCL
• MCL
• LCL
• Posterolateral corner
• Posteromedial corner
15
ACL injuries
• Reconstructed or not – osteoarthritis?
• Chronic ACL deficiency – results with complex
meniscal and chondral lesions
• More common in female
• Indirect injuries
• External rotation and valgus injuries
16
ACL injuries
• History
– Indirect pivot injuries
– Pop sensation and sudden hemarthrosis
• P.E.
– Anterior drawer test
– Lachman test (most sensitive)
– Pivot shift test
• Diagnostic tools
– Arthrometer ; measures laxity
– Xray ; segond fracture (lateral capsular
sign)
– MRI ; most sensitive
17
ACL injuries: Treatment
• Conservative – sedantery, old
• Reconstruction – young, active
– Graft choice?
– Technique?
• Primary repair -- controversial
18
PCL injuries
• Anterior force to tibia
• Posterior drawer test
• Xray
– Avulsion injuries
– Arthrosis
– Stress graphy
• MRI
• Treatment
– Functional PCL and stable knee (partial or isolated total);
conservative
– Avulsion injuries; fixation
– Unstable knee; reconstruction
19
MCL injuries
• Valgus stress injuries
• Diagnosis: pain and instability with valgus stress
– Only at 30 degrees flexion; isolated injury
– Also in extension; associated injuries (ACL and/or PCL)
• Pellegrini Striada sign
– Chronic MCL injury
– Calcification of medial femoral condyle insertion
• Treatment
– İsolated ; conservative with brace
– Associated injuries should be reconstructed with MCL repair
20
LCL injuries
• Varus laxity in 30 degrees of flexion
• Stable knee; conservative (rehabilitation and
brace)
• Unstable knee; LCL repair and posterolateral
corner reconstruction
21
Posterolateral corner injuries
• Rarely isolated, commonly associated with
other ligament injuries
• Posterolateral drawer test
• Dial test
• PL repair and reconstruction of associated
injuries
22
Osteochondral Lesions
• Osteochondritis dissecans
• Articular cartilage injury
• Degenerative joint diseases
• Osteonecrosis
23
Osteochondritis dissecans
• Articular cartilage and subchondral bone
dissection following occult trauma
• Commonly occurs in lateral surface of medial
femoral condyle
24
Osteochondritis dissecans
• Diagnosis
– Unspecific complaints
– X ray
– MRI
• Spontaneous healing
– in most of the juvenile patients
– %50 of adolescent patients
– Rarely in adults
25
Articular cartilage injuries
• Rotational forces caused by direct trauma
• Medial femoral condyle most commonly affected
• Arthroscopic classification
– Gr 1 softening, Gr2 <%50 fissure, Gr3 >%50 fissure, Gr4 total defect
• Treatment
– Debridement&chondroplasty
– Displaced osteochondral fragment – fixation
– Cartilage defect
• Microfracture
• Mosaicoplasty (osteochondral autograft transplantation)
• Autologus chondrocyte transplantation
• Periostal patches
• Osteochondral allografts
26
Synovial Lesions
• Pigmented villonoduler synovitis
– Excessive formation of synovium
– Noduler or diffuse form
– Recurrence risc in diffuse form
– Treatment: synoviectomy + ?radiation?
• Synovial chondromatosis
– Proliferative synovial disease charactherised with cartilaginous metaplazia
– Loose bodies in the joint
• Plica
– Embryologic synovial folds
– Sometimes pathologic causing chondral abrasion
– Esp. Medial patellar plica
– Excision if pathologic
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Patellofemoral disorders
Acute Trauma
Contusion
Fracture : patella, femur, tibia
Dislocation
Tendon rupture: quadriceps, patellar tendon
29
Patellofemoral disorders
Overuse injuries
Patellar tendinitis (jumper knee)
Quadriceps tendinitis
Prepatellar bursitis
Apophysitis
-Osgood Schlatter
-Sinding Larsen Johansson
30
Patellofemoral disorders
Late effects of trauma
Posttraumatic chondromalacia patella
Patellofemoral arthritis
Anterior fat pad syndrome (posttraumatic
fibrosis)
Complex regional pain syndrome
31
Patellofemoral disorders
Lateral patellar compresion syndrome
Chronic subluxation of patella
Recurrent dislocation of patella
Chronic dislocation of patella
• They result secondary chondromalacia patella
or patellofemoral arthritis
32
Patellofemoral disorders
Idiopathic chondromalacia patella
Osteochondritis dissecans
Synovial plica
-Medial patellar
-Suprapatellar
-Lateral patellar
33
Pelvis, Hip and Thigh Injuries
• Contusions
• Muscle injuries; Hamstring-quadriceps
• Bursitis; ischial, trochanteric, iliopsoas
• Bone disorders; stress fractures, fractures,
avasculer necrosis, osteitis pubis
– Osteitis pubis: repetitive trauma cause
inflammation of symphisis pubis. Frequent in
runners and football players. Generally treated
conservatively.
34
Hip Intraarticular injuries
• Loose body
• Labral tears
• Cartilage injuries
• Ligamentum teres rupture
35
Femoroacetabular Impingement
• Anormal relation between proximal femur and
acetabulum
• Cartilage damage cause symptoms
• Cam type (femoral origin)
• Pincer type (acetabular origin)
36
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Snapping hip
• Iliotibial band (external)
• Iliopsoas (internal)
38
Leg, Ankle &Foot injuries
• Nerve entrapment syndromes
• Muscle injuries
• Tendon injuries
• Chronic compartment syndrome
• Fractures
• Plantar fasciitis
• Ankle impingement
– Anterior (talotibial or talofibular)
– Posterior (os trigonum)
• Ankle distortions
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Leg, Ankle &Foot injuries
• Nerve entrapment
– Saphen nerve
– Peroneal nerve
– Tibial nerve
– Branch of lateral plantar nerve (baxter nerve)
– Medial plantar nerve
– Sural nerve
– Interdigital nerve
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41
Leg, Ankle &Foot injuries
• Muscle injuries
– Gastrocnemius and soleus
injuries are common
– Related with tennis
42
Leg, Ankle &Foot injuries
• Tendon injuries
– Peroneal
• Subluxation or dislocation
• Tendinitis
• Rupture
– Tibialis posterior tendon injuries
– Tibialis anterior tendon injuries
– Achilles tendon injuries
• Tendinitis and tendinozis
• Rupture
– Kick sensation
– Thompson test
– Usg or MRI
– Conservative ? or surgery
43
Leg, Ankle &Foot injuries
• Chronic compartment syndrome
– Especially in runners and cyclists
– Gradually increasing pain with exercise
– Limits performance
– Anterior compartment of the leg is most common
– 20 mmHg – 5 minutes after exercise
44
Leg, Ankle &Foot injuries
• Fractures
– Stress fractures
• Tibia shaft
• Navicula
• Freiberg infarct
– Flattening of second
metatarsal head cause
of overload
– especially in children
– Conservative
– Jones fractures
45
Leg, Ankle &Foot injuries
• Ankle distortions
– Frequent injury
– Atfl is most commonly effected
– Ottowa criteria (Tenderness? Weight bearing?)
• Plantar fasciitis
– Common in runners
– Inflammation of plantar fascia
– Conservative treatment
– Extracorporeal shock wave
– Rarely surgery
46
Shoulder Anatomy
47
Shoulder Biomechanics
• Stability
– Static factors
• Glenoid labrum
• Joint congruency and version
• Negative intraarticular pressure
• Capsule
• Glenohumeral and coracohumeral ligaments
– Dynamic factors
• Predominantly rotator cuff muscles
• Scapular stabilizers
– Levator scapula
– Trapezius
– Serratus anterior
– Rhomboid
• Long head of the biceps tendon
• Coordinated scapulothoracic rhythm
• Proprioceptive mechanoceptors in the
capsule
48
Shoulder injuries
• Instability
• Rotator cuff diseases
• Superior labral and biceps tendon injuries
• Acromioclavicular and sternoclavicular injuries
• Muscle injuries
• Calcific tendinits
• Frozen shoulder
• Nerve diseases
• Glenohumeral arthrosis
• Snapping scapula (scapular crepitus)
• Wing scapula
• Little leaguer’s shoulder
49
Shoulder injuries
• Diagnostic tests
– History
• Age
– Instability and acromioclavicular injury are more common in
young age
– Rotator cuff injury and arthrosis are more common in old age
• Main complaint
– AC seperation --Pain over acromioclavicular joint after direct blow
– Instability --Apprehension while shoulder is in abduction and
external rot.
– Rotator cuff injuries -- Chronic overhead shoulder pain and night
pain
50
Shoulder injuries
• Physical examination
– Inspection
– Palpation
– ROM
– Pain and apprehension during ROM
– Special tests
51
Shoulder injuries
Rotator cuff injuries Instability
• Impingement sign • Apprehension test
• Impingement test • Relocation test
• Hawkins test • Load and shift test
• Drop arm • Jerk test
• Hornblower • Sulcus sign
• Liftoff test
• Belly-push test Biceps pathology
• Speed test
• Yergason test
52
Shoulder injuries
Instability
• Instability: Recurrent dislocation of shoulder
joint
• High instability risc cause of wide ROM
• Most commonly dislocated joint in the body
• Named with the dislocation side
• Anteroinferior dislocation is most
common(%90-95)
• Shoulder dislocation results with wide range of
injury to the shoulder stabilizers.
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Shoulder injuries
Instability
• Dislocation mechanism
– Anterior – abduction and external rotation
– Posterior- seizures, electrocaution, direct
anteroposterior blow
– Superior – fall on elbow while shoulder is neutral
– Luxatio erecta(inferior) – sudden suspension injury
55
Shoulder Instability
TUBS AMBRI
• Traumatic • Atraumatic
• Unilateral • Multidirectional
• Bankart • Bilateral
• Surgery • Rehabilitation
• Inferior capsular plication
56
Shoulder Instability
• Associated injuries causing recurrent
dislocations
– Bankart
– Hill sachs
– HAGL
– Capsular pouch
• Recurrent dislocation risc is higher in younger
age
57
58
Shoulder Instability Treatment
• Treatment should target pathology
• Bankart lesion – repair
• Hillsachs lesion – grafting
• Latarjet – coracoid transfer to glenoid
• Etc…
59
Impingement syndrome/Rotator cuff
disease
• Mild impingement
• Partial rotator cuff tear
• Total tear
• Massive tear
• Rotator cuff arthropathy
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Function
• Keep the humeral head centered on the
glenoid regardless of the arm’s position in
space.
• Generally work to depress the humeral head
while powerful deltoid contracts
62
Pathophysiology
• Intrinsic Factors
– Vascular supply (? significance)
• Distal 1cm of supraspinatus tendon (early studies)
• Hypervascularity with tendonitis
– Degenerative changes
• Age related
• Change in proteoglycan and collagen content in
symptomatic tendons
63
Pathophysiology
• Extrinsic factors
– Impingement
• Acromial spurs
– Type III acromion and
decreased geometric area of
the supraspinatus outlet
» Increased prevalance of
symptomatic cuff disease
• Coracoacromial ligament
• AC joint osteophytes
• Coracoid process
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Pathophysiology
• Extrinsic factors
– Repetitive use
• Tensile overload
• Muscle fatigue
• Microtrauma
65
Incidence
– MRI of asymptomatic volunteers
• Normal, painless function
• 19 to 39
– 0% full thickness
– 4% partial (1 of 96)
• 40 to 60
– 4% full thickness
– 24% partial thickness
• Over 60 years old --> 54% incidence
– 28% full thickness
– 26% partial thickness
66
Classification
Partial Bursal vs Articular
< 50% thickness
> 50% thickness
Complete
Organize by size –small 1 cm>, medium1-3 cm, big
3-5 cm, massive 5cm<
Number of muscles involved
67
Mechanism
Traumatic vs Chronic/Insiduous
68
History
• Pain on the lateral aspect of the shoulder
– may radiate to deltoid insertion
– anterior acromion with impingement
• +/- biceps tendonitis
• Stiffness, esp IR
• Cannot lie on that side
• Weakness, instability, crepitus
• Partial tears more sore and stiffer
• Acute tear may have inciting event
69
Physical Exam
• Inspection: atrophy, symmetry
• Palpation: AC, cuff tenderness
• Range of motion: active, passive
• Strength: ER and elevation power, lag
• Provocative: impingement sign, arc of pain
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Physical Exam
• Impingement testing
(NEER SIGN)
• Shoulder internally rotated,
examiner forward flexes the
patient’s arm, pushing the
supraspinatus against the
anteroinferior acromion, with
increased shoulder pain signifying
rotator cuff inflammation or tear
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Physical Exam
Hawkin's test
• With patient’s arm abducted to 90°, then shoulder
internally rotated, pushing the supraspinatus against the
anteroinferior acromion, with increased shoulder pain
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Physical Exam
• SUBSCAPULARIS
• Gerber's lift off test: push
examiner's hand away from 'hand
behind back position'
• Internal rotation lag sign: inability
to hold hand away from back
• Belly push (Napoleon test): if pt
cannot fully internally rotate, pt.
pushes on their belly, elbow will
drop backwards if +ve
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Physical Exam
SUPRASPINATUS
• Jobe's Test:
arm abducted in the
plane of the
scapula, thumb
pointing down .
Resist elevation of the
arm.
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Physical Exam
• TERES MINOR
Hornblower's sign:
90º shoulder
flexion, elbow 90º,
resisted ER (teres
minor)
75
Imaging
• Plain radiographs
– AP -glenohumeral arthritis, calcific
tendonitis, migration of humeral head
superiorly, greater tuberosity changes (cysts
or sclerosis indicating chronic tear)
– Lateral (supraspinatus outlet)
• Evaluates acromion type and
subacromial spurs
• USG
• Arthrography
• MRI
76
Treatment
• Mainstay is conservative
• Surgery reserved for significantly symptomatic
patients who have failed conservative
management
• Younger patient (<60) with acute tear
– Cuff repair within 6 weeks
77
Treatment
Conservative Treatment Surgery
• Rest • Open
• NSAİD • Arthroscopic
• Activity modification
• Physical therapy Decompression
• Subacromial injection Partial bursectomy
Rotator cuff repair
78
Biceps tendinitis
• Inflammation of biceps tendon
• Associates with impingement syndrome,
rotator cuff tears and narrowing of bicipital
groove
79
Biceps tendinitis
• Diagnosis
– Speed test
– Yergason test
– Imaging --- USG, MRI
– Treatment
• Conservative
• Tenotomy (cause deformity)
• Tenodesis
80
Acromioclavicular diseases
• AC seperation
– 6 types
– Mechanism: fall over shoulder
– Type 1-2 conservative
– Type 3 conservative or surgery
– Type 4-5-6 surgery
• AC degeneration
– Arthrosis
– Palpaple hypertrophy
– Pain with adduction
– Treatment
• Conservative
• Surgery – distal clavicular resection
81
Muscle tears
• Pectoralis major
– Pain and weakness
– Swelling, echymosis, palpable
defect
– Only in man
– Surgical repair
• Deltoid
– Total rupture is unusual
– Strain or partial tear
– Iatrogenic injury during shoulder
surgery
82
Calcific tendinitis
• Idiopathic
• Self limiting
• Supraspinatus generally effected
• More common in women
• Charactheristic calcification in
tendon
• Diagnosis: Xray
• Treatment
– Physical therapy
– Needle aspiration
– Debridement (arthroscopic or open)
83
Frozen Shoulder
• Adhesive capsulitis
– Pain and limitation in glenohumeral ROM especially
external rotation
– Related factors: Diabetis, breast surgery, prolonged
immobilisation, autoimmune thyroid diseases
– Coracohumeral ligament and joint capsule effected
– NSAID, GH steroid injection, physical therapy
– Resolution within 12 weeks
84
Nerve diseases
• Brachial plexus injury
– American football
– Shoulder peds compress brachial plexus
– Burning and stinging sensation
– Compression or traction injuries
• Thoracic outlet syndrome
– Vessels and nerve compressed between 1 st rib and scalene muscles
– Pain and ulnar paresthesia
– Wright test: servical rotation, shoulder extended and extrenal rotated
– Conservative // 1 st rib resection
• Long thoracic nerve palsy
– Serratus anterior dysfunction
– Medial scapular winging
– Compression or traction injuries
– Spontaneous resolution
85
Nerve diseases
• Suprascapular nerve entrapment
– Suprascapular notch
• Supraspinatus&infraspinatus atrophy
– Spinoglenoid notch
• Infraspinatus atrophy
– Ganglion, fracture callus etc.
• Quadrilateral space syndrome
– Pain and paresthesia
– Teres minor and deltoid atrophy and
weakness with overhead injuries
86
Glenohumeral arthrosis
• More common in olders
• Throwing sports – younger age
• Instability and rotator cuff diseases may cause
arthrosis
• Pain, decreased ROM
• Treatment
– Conservative
– Arthroscopic debridement
– Arthroplasty
87
Snapping Scapula
• Shoulder elevation cause scapulothoracic
crepitus and pain
• Bursitis or bone lesions (osteochondroma)
between scapula and thorax
• Strengthening, NSAID, local steroid injections
• Bursectomy or lesion excision
88
Little leaguer’s shoulder
• Young baseball sporters
• Repetitive throwing (overuse of
shoulder)
• Salter Harris type 1 fractures or
proximal humerus stress
reactions
• Xray: Enlargement of proximal
humeral physis
• MRI – exact diagnosis
• Treatment – rest and activity
modification
89
Elbow Anatomy
90
Elbow injuries
• Tendon injuries
• Ligament injuries
• Osteochondritis dissecans
• Little leaguer’s elbow
• Osteoarthritis
91
Elbow tendon injuries
• Lateral epicondylitis (tennis elbow)
– Pain over forearm extensors and lateral
epicondyle
– Caused by repetitive supination and pronation
– Microtears (Ext. Carpi radialis brevis …)
– Pain with wrist extension and supination against
resistance
– Conservative treatment
– Rarely surgery (debridement)
• Medial epicondylitis (golfer elbow)
– Overuse of flexors/pronators of forearm
– Rare than lateral epicondylitis
– Pain with wrist flexion and pronation against
resistance
– Conservative treatment
– Rarely surgery (debridement)
92
Elbow tendon injuries
• Distal biceps tendon rupture
– Eccentric overload to flexed
elbow
– %50 weakness of supination
– Surgical repair
• Distal triceps tendon avulsion
– Flexion force to extending
elbow
– Related with multiple
cortisone injections
– Surgical repair
93
Elbow ligament injuries
• Ulnar collateral ligament injury
– High energy, repetitive valgus stress
– Weakening and rupture of anterior band
– Pain over medial side
– Ulnar nerve problems are possible
– Valgus instability %50
– Imaging: MRI
– Conservative treatment
– Surgical reconstruction in professional sporters
• Radial collateral ligament injury
– Associates elbow dislocations
– Instability – surgical reconstruction
94
Elbow Injuries
• Osteochondritis dissecans
– Adolescent sporters
– Capitellum is affected
– Stable fragment
• Activity modification and support treatment
– Unstable displaced fragment
• Reduction and fixation
• Excision and microfracture
95
Elbow Injuries
• Little leaguer’s elbow
– Medial epicondyle stress fracture
– Adolescent
– Throwing sport
– Repetitive valgus load
– Treatment : rest and activity modification
96
Trigger Finger
97
De Quervain Tenosynovitis
98
Thanks for your patience…
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