29. | Manual of Rheumatology and Outpatient Orthopedic Disorders (LB Spiral Manuals)

Chapter 22 Sports Injuries

Manual of Rheumatology and Outpatient Orthopedic Disorders

Chapter 22 Sports Injuries

Riley J. Williams and Thomas L. Wickiewicz

Cervical spine
Thoracolumbar spine
Shoulder
Elbow
Hand
Knee (ligamentous injuries)
Running injuries

During the past decade , the importance of regular exercise in the maintenance of good health has been well established. Consequently, with increasing attention now focused on personal fitness, the incidence of sports- related injuries has increased significantly. Both primary care physicians and specialists can expect to see a variety of athletic injuries. All clinicians should be able to recognize these conditions and administer appropriate care. A thorough history, physical examination, musculoskeletal imaging, and laboratory testing are all important in arriving at the proper diagnosis. A treatment plan is then developed for the injured athlete based on these objective findings.

I. Cervical spine. Injuries to the cervical spine range from mild to severe. Certain athletic activities (football, diving, gymnastics) are associated with an increased incidence of cervical spinal injury in comparison with other sports. Prompt recognition and treatment of persons who suffer cervical spinal injuries may prevent the progression or severity of the associated neurologic injury .

Anatomy. See Chapter 14.
Classification of cervical spinal injuries. Neck injuries can be classified according to neurologic sequelae or the type of force acting on the cervical spine at the time of injury.
1. Cervical spinal injury with minimal, transient, or no neurologic symptoms
  1. Muscle strains. Pain and neck stiffness with no neurologic findings and negative imaging studies. Usually resolve spontaneously.
  2. Brachial plexus injuries ( stingers or burners ). Transient symptoms. See below.
  3. Bony fracture, ligamentous injury, disk injury without neurologic involvement.
2. Cervical spinal injuries accompanied by incomplete or complete spinal cord syndromes
Classification by mechanism of injury and syndrome
1. Flexion without axial load or rotation. These forces usually cause a compression fracture of the cancellous cervical vertebral body without tearing of the stabilizing ligamentous complex of the facet joints. Avulsion fractures of the transverse processes can also occur. These are stable fractures usually not associated with neurologic loss.
2. Flexion with rotation. These forces place high loads on the facet joint capsules and the posterior interspinous ligaments. Unevenly applied forces can cause unilateral facet dislocation resulting from facet capsular rupture . Larger loads can lead to bilateral facet dislocations with associated anterior subluxation of the vertebral bodies and fractures of the facets, laminae, or vertebral bodies. Neurologic injury associated with these injuries is quite variable, ranging from no loss to complete spinal cord injury.
3. Axial compression. This type of load usually results when the head strikes a hard object, as when a swimmer dives into shallow water. With forward flexion of the head, cervical lordosis is decreased such that the spinal column is essentially straight. The resultant force is transmitted to the cervical spine and can cause vertebral body fracture with retropulsion of bony elements into the spinal canal. Neurologic loss, including quadriplegia or complete motor paralysis secondary to anterior spinal cord syndrome, is commonly associated with this injury pattern.
4. Extension. Extension forces that exceed the normal range of motion of the cervical spinal facet joints can lead to fracture of these elements or an avulsion of the superior margin of the vertebral body. Neurologic loss is variable. Occasionally, the spinal cord impingement occurs between the lamina posteriorly and a disk anteriorly. A complete spinal cord injury or central cord syndrome can result.
Spinal cord syndromes
1. Central. Extension forces. Injury affects upper more than lower extremities. Motor and sensory loss. Fair prognosis . Most common type.
2. Anterior. Flexion-compression. Incomplete motor and sensory loss. Poor prognosis.
3. Brown-S quard. Results from penetrating trauma. Ipsilateral loss of motor function; contralateral pain and loss of temperature sensation . Best prognosis of all syndromes.
4. Complete. Spinal canal disruption, canal compression. No function below injury. Poor prognosis.
5. Single root. Avulsion or compression (disk). Symptoms related to level. Good prognosis.
Physical examination. In suspected cervical spinal injuries, a brief screening examination should be administered to assess the magnitude of the injury at the scene.
1. Observation. The position of the head and neck at impact should be noted to categorize the mechanism of injury.
2. History
  1. In the on-site evaluation after cervical spinal injury, the examiner must first apply the basic ABCs of resuscitation. When unconsciousness follows neck injury, basic life-support measures should be applied.
    Note: Hyperextension of the neck should be avoided during these efforts.
  2. If the patient is awake and alert, a history is taken to establish whether consciousness was lost (amnesia for the event).
  3. The location and quality of any pain (neck, arms, shoulders, hands, back, or legs) is noted.
  4. Numbness patterns must be defined. In the event of complaints of numbness, the clinician must define whether the pattern is global (all extremities) or partial (upper vs. lower extremities) and whether it was transient or is persistent.
3. Motion. If the patient is not amnesic for the event, did not lose consciousness, and has no self- reported neurologic loss, the clinician can then encourage the patient to attempt active range of motion of the neck without assistance. If significant pain is encountered , the neck should be immobilized and the patient further evaluated.
4. Neurologic examination
  1. Sensory examination. This portion of the examination should include tests of sharp versus dull discrimination, light-touch sense, deep pressure, vibration , and position sense in all extremities.
  2. Motor examination. Muscular strength should be assessed and graded in all limbs. Reflexes should also be graded in all limbs .
  3. Rectal examination. In cases of spinal cord injury, the rectal examination is the most important part of the examination and can help the clinician discriminate between complete and incomplete spinal cord lesions after the resolution of spinal shock .
    Note: This procedure, although important, is not part of the on-site evaluation.
Radiographs
1. Standard cervical spinal radiographs include anteroposterior, lateral, oblique , and odontoid views. If there is no evidence of fracture or dislocation, a flexion-extension view of the cervical spine is also obtained. Active neck flexion and extension are always performed by the patient alone and should not exceed the patient's reported comfort level. The spinal column is considered unstable when vertebral body subluxation in excess of 3.5 mm or an angular deformity of 11 degrees or more exists.
2. Supplemental radiographs consist of pillar views to evaluate the lateral masses. Computed tomography (CT) can be used to detect subtle fractures and evaluate the spine for rotatory subluxation. Magnetic resonance imaging (MRI) is also very useful in the evaluation of soft- tissue abnormalities (ligamentous disruption, disk protrusion).
Treatment. The most important aspect of the management of cervical spinal injury is immobilization. Neck immobilization should be maintained until a definitive diagnosis has been made. For example, football-related cervical spinal injuries are managed by transporting the patient (with helmet in place) on a backboard. The patient is log-rolled onto a backboard with vigilant head stabilization. The face guard is left in place unless respiratory difficulty is encountered, in which cases it is removed. The neck is never moved passively until a fracture or dislocation is ruled out.
Note: In cases of spinal cord injury, the administration of IV methylprednisolone should be strongly considered because this agent has been shown to improve neurologic recovery if given within 8 hours of injury.
Common cervical spinal problems
1. Burners or stingers. These injuries represent a stretch of the brachial plexus with a transient loss of motor power and transient pain radiating down the arm(s). This phenomenon usually occurs in football players. Most often, the symptoms are temporary and usually resolve within 1 to 2 minutes. The person can generally return to play the day of injury. With more severe brachial plexus injuries (i.e., persistent pain or weakness), nerve damage may result. Consequently, neurologic loss and pain will persist. These athletes cannot return to play and should be carefully examined in a controlled, off-field setting.
2. Ligamentous sprain. These injuries occur when a force moves a joint through an abnormal range of motion. This condition presents with localized neck pain and muscle spasm. The neurologic and radiographic examination findings are usually normal. Treatment consists of immobilization (semirigid collar ), local heat, muscle relaxants, antiinflammatory medicines, and restriction of activity. Athletes can return to play when the symptoms resolve.
3. Cervical spinal fractures ”stable. These types of fractures include C-1 burst fractures (Jefferson fracture), most odontoid fractures, traumatic C-2 spondylolisthesis (hangman's fracture), compression fracture of a vertebral body without comminution, and spinous process fracture (clay shoveler's fracture). Most of these fractures are treated with rigid immobilization (halo vest) until healing is complete.
4. Cervical spinal fractures and subluxation ”unstable. Cervical spinal subluxation/dislocation usually presents with neurologic loss. These injuries require immediate immobilization and should ultimately be reduced. MRI is useful for assessing soft-tissue damage in these cases. Cervical traction or surgical reduction and stabilization are frequently indicated.
5. Cervical disk herniation. This phenomenon is uncommon in young athletes but may be seen in axial compression injuries sustained during rugby or football. Again, MRI is the best diagnostic modality for assessing patients for potential disk problems.

II. Thoracolumbar spine. Repetitive stresses to the ligamentous and bony supports of the thoracic (dorsal) spine can result in an overuse syndrome with subsequent acute or chronic back pain. Spondylolysis is a unilateral or bilateral fracture of the pars interarticularis. This lesion is frequently nontraumatic and may represent a congenital lesion or stress fracture. However, spondylolysis can occur acutely, especially in gymnasts, weight lifters, and football linemen. Spondylolisthesis is a fracture of the pars interarticularis, which is associated with translation of one vertebral body over another. It is frequently observed in the lumbar spine, especially at the L5-S1 junction.

History. Pain is usually localized to the low back and, less commonly, to the buttocks and posterior thighs. Radicular symptoms are uncommon.
Physical examination. Hamstring tightness is common. Point tenderness may be noted along the dorsal thorax.
Diagnostic studies. Oblique views of the lumbosacral spine usually demonstrate the spondylolytic lesion (lucency at the neck of the Scotty dog ). A stress fracture of the pars interarticularis that is not obvious on plain radiographs may be demonstrated by means of bone scintigraphy.
Treatment consists of local measures, including heat, nonsteroidal antiinflammatory drugs (NSAIDs), muscle relaxants, and rest during the acute period. Modification of activity or bracing is usually required. Surgical fusion is indicated only in cases of severe spondylolisthesis or unrelenting pain.

III. Shoulder. Sports that require repetitive overhead arm motion (baseball, racquet sports, swimming) place unusual stresses on the supporting structures of the shoulder. Injuries to the shoulder capsule , rotator cuff musculature, biceps tendon, scapular stabilizers, and shoulder musculature are common. Most of these problems are discussed in Chapter 15. Additional shoulder problems, unique to overhead athletes, are discussed in this section.

Little Leaguer's shoulder typically affects adolescents and teen-agers and represents a separation of the proximal humeral epiphysis. The observed physeal abnormality is likely caused by repetitive forces associated with the acceleration phase of the pitching cycle (extreme humeral abduction and external rotation to forward flexion and internal rotation).
1. History. These typically young patients complain of arm pain during and after throwing.
2. Radiographs reveal widening of the proximal humeral growth plate and demineralization and fragmentation adjacent to the epiphyseal plate. Occasionally, loose bodies are noted in the glenohumeral joint.
3. Treatment is conservative. Patients are prohibited from throwing until clinical and radiographic healing has occurred.
Rotator cuff tendinitis usually occurs as a result of overuse or in cases of subtle glenohumeral subluxation. It responds well to conservative measures (ice, NSAIDs, rest). Rehabilitation is most effective in relieving symptoms.
Posterior capsular tears, which occur in throwers, can result in ossification of the posterior capsule near the glenoid labrum. These lesions occur secondary to traction on the capsule during the acceleration and follow-through phases of the pitching cycle. Treatment initially consists of rest, NSAIDs, strengthening exercises, and restriction of pitching.
Internal impingement syndrome typically occurs in baseball pitchers. Lesions occur at the posterosuperior margin of the glenoid in the undersurface of the rotator cuff tendons (partial tears). These lesions are attributed to impingement of the rotator cuff on the bony margin of the glenoid during the cocking phase of the pitching motion (abduction, external rotation). Treatment is conservative (activity modification, NSAIDs). Recalcitrant cases may require debridement of the lesion.
Instability. Global instability (anterior, posterior, inferior) of the shoulder can occur in overhead athletes because of microtrauma to the shoulder capsule. The shoulder usually does not frankly dislocate but rather feels loose to the patient. Many cases can be treated with physical therapy ; surgical stabilization may be necessary in severe cases.

IV. Elbow. The diagnosis and treatment of problems of the elbow require an understanding of the anatomy and function of the joint.

Anatomy and function. The elbow is a hinge joint. Elbow flexion and extension occur at the articulation of the humerus and ulna. Rotation takes place at the proximal radioulnar and radiocapitellar joints.
Joint stability. During valgus stress, primary stability is derived from the bony fit of the ulnohumeral and radiocapitellar joints. Secondary stability is derived from the restraint provided by the medial (ulnar) collateral ligament. The lateral (radial) collateral ligament and the anconeus muscle provide some resistance to varus loads; however, bony constraint is much more important in resisting these forces. Most throwing activities subject the elbow to valgus stress.
Common elbow problems. Overhead athletes (throwers, tennis players) place tremendous, repetitive valgus forces on the medial side of the elbow. These forces result in the application of compressive forces on the lateral elbow during the acceleration phase of throwing. Forceful extension during follow-through (extension overload) leads to posterior compartment lesions (loose bodies, osteophytes). Medial elbow tension-overload injuries include acute valgus instability and chronic valgus instability, both of which can be complicated by ulnar neuropathy.
1. Acute valgus instability
  1. Flexor mass tears. These lesions occur at the elbow in association with sudden forced wrist flexion and pronation. Tenderness and pain at the point of the tear are noted with resisted wrist or finger flexion. Partial tears are initially treated with rest, ice, and NSAIDs. This is followed by resistive exercises at the wrist. Complete tears present with a palpable soft-tissue defect distal to the flexor muscle origin and may require surgical reattachment.
  2. Medial (ulnar) collateral ligament tears (acute). These lesions present with pain and tenderness during valgus stress of the elbow. Laxity with valgus testing at 30 degrees of flexion confirms the diagnosis. MRI is useful in distinguishing between complete and partial medial collateral ligament injuries. Partial tears are treated with ice, rest, early motion, and a gradual return to full activity. Complete tears require surgical repair/reconstruction in high-level athletes who wish to continue throwing.
  3. Little Leaguer's elbow. Repetitive valgus stresses in children can cause epiphyseal avulsion of the medial epicondyle rather than ligamentous rupture. Treatment is usually conservative (ice, rest, early motion).
  4. Athletes at risk are pitchers, catchers, and javelin throwers.
2. Chronic valgus instability is common in athletes involved in throwing sports. Medial collateral ligament laxity develops slowly over time and occurs secondary to the microtrauma associated with repetitive throwing. Traction spurs at the distal insertion of the medial collateral ligament and calcification within the ligament can occur. Chronic ligamentous laxity may require surgical excision of calcified deposits and spurs, debridement, and reefing of the medial collateral ligament or reconstruction with use of the palmaris longus tendon. Loose bodies can also form within the elbow joint as a result of this condition, so that elbow arthroscopy is generally performed on patients undergoing reconstruction of the medial collateral ligament.
3. Ulnar neuropathy can develop secondary to ulnar nerve compression at or near the elbow (cubital tunnel). Affected patients present with pain along the ulnar groove, with radiation of pain and paresthesias into the fourth and fifth fingers. In most patients, Tinel's sign is positive at the elbow. Electromyographic and nerve conduction studies may be required to confirm the diagnosis. Studies have demonstrated that this condition often accompanies chronic laxity of the medial collateral ligament of the elbow. Initial treatment consists of rest and NSAIDs. Decompression of the cubital tunnel and nerve transposition may be required.
4. Lateral compartment injuries
  1. Osteochondritis dissecans. Valgus forces at the elbow result in compressive loading of the lateral side. Osteochondritis dissecans of the humeral capitellum frequently occurs in male adolescents 12 to 14 years of age.
    1. History. The thrower presents with pain, motion loss, and catching or locking symptoms.
    2. Radiographs usually reveal flattening of the capitellum (most common site) or fracture.
    3. Differential diagnosis includes Panner's disease, which has a similar radiographic appearance but is found in younger patients (6 to 9 years) and is not related to trauma.
    4. Treatment of osteochondritis dissecans depends on the size of the lesion. Small osteochondral lesions are managed by activity modification and antiinflammatory medications. Large lesions or loose bodies may require surgical debridement (elbow arthroscopy).
  2. Lateral epicondylitis (tennis elbow) causes pain at the lateral humeral epicondyle. Although commonly found in participants in racquet sports, this malady also occurs in persons who do not play tennis.
    1. Pathogenesis. The site of pathology is generally found at the origin of the extensor muscle (extensor carpi radialis brevis) at the lateral epicondyle. The period of peak incidence is the fourth decade of life. This finding suggests a degenerative process in the tendon aggravated by repetitive stress, which leads to macroscopic and microscopic tears of the extensor origin. Approximately 40% of these patients will have other sites of soft-tissue degenerative problems (shoulder bursitis, rotator cuff tendinitis).
    2. History. Patients typically present with lateral elbow pain that is exacerbated by wrist extension. They commonly complain of pain while they are using a screwdriver, shaking hands, making a fist, or lifting a weight. The pain radiates from the dorsum of the forearm to the fingers. Tennis players often complain of accentuated pain during backhand strokes. Numbness or paresthesias may occur. Such complaints should alert the physician to consider other causes of elbow pain (i.e., cervical radiculopathy). A history of fluoroquinolone antibiotic (i.e., ciprofloxacin) use may also be reported.
    3. Physical examination. Point tenderness at the lateral epicondyle is typical. Tenderness may also be present distally along the extensor muscle sheaths. Resisted wrist extension with the elbow straight and the hand and forearm pronated should reproduce symptoms.
    4. Radiographs. Calcification may be seen in the region of the lateral epicondyle, but the elbow joint itself is normal.
    5. Differential diagnosis
      1. Medial epicondylitis (golfer's elbow) is an inflammatory condition that leads to pathology within the origin of the flexor pronator muscle group and pain at the medial epicondyle.
      2. Intraarticular pathology. A patient with elbow pathology (loose bodies, RA, osteoarthritis ) may present with lateral elbow pain. Limitation of elbow motion and radiographic changes can clarify the diagnosis.
      3. Gout. Differentiation is not difficult because the acute, inflammatory signs of gout (erythema, swelling) are not usually present in tennis elbow. Crystals found on joint aspiration will confirm the diagnosis of gout.
      4. Cervical spinal disease may cause referred pain to the elbow. MRI of the cervical spine can be useful.
      5. Posterior interosseous nerve (branch of radial nerve) entrapment may mimic lateral epicondylitis. Tenderness is more volar over the entrance of the nerve into the supinator muscle.
    6. Treatment is initially conservative. Activities that accentuate the pain are avoided for 8 to 12 weeks. Oral NSAIDs should be given acutely for pain relief. Should symptoms persist, injection of 40 mg of methylprednisolone acetate (Depo-Medrol) with 1 mL of 1% lidocaine into the point of maximum tenderness usually provides some relief. When the acute pain has subsided, exercises directed at strengthening the extensor muscles are started. A flexibility program is also started, and ice is used judiciously. A forearm band may reduce tension on the extensor muscle origin and provide relief in some patients. A volar wrist splint may also be helpful. Surgical excision of the degenerative tissue at the origin of the extensor carpi radialis brevis may be necessary in patients who fail conservative treatment.
    7. Prevention
      1. Awareness. Warm-up, stretching, exercise, and weight-lifting programs serve as prophylactic measures and should be encouraged.
      2. Warm-up. Abrupt physical stresses may predispose certain muscle groups to injury. Appropriate warm-up activity should precede vigorous racquet sports. For example, the first 15 to 20 minutes of tennis should consist of low-intensity volleying. Speed and duration should be gradually increased. Stretching and ice application for 15 minutes should follow all activities.
      3. Technique. Poor technique is one of the main causes of tennis elbow. Patients with lateral epicondylitis should pay specific attention to grip and the technique of backhand strokes. Lighter racquets, large grip size, and less taut stringing (52 pounds ) have all been reported to be helpful. Clay is a better surface, and opponents should be selected who hit at lower speeds.

V. Hand. The hand is exposed to many forces that may result in significant injury in the course of athletic activity.

Bennett's fracture is a fracture of the base of the first metacarpal.
1. History. The mechanism of injury is a direct blow against a partially-flexed metacarpal or a fall on an outstretched hand while a ski pole is clutched.
2. Physical examination. Swelling and tenderness are present at the carpometacarpal joint, and deformity of the thumb is present, particularly if the joint is dislocated.
3. Radiographs. The fracture line characteristically separates the major part of the metacarpal from a small volar lip fragment, disrupting the carpometacarpal joint.
4. Treatment. Closed or open reduction with pinning is required to reestablish articular congruity.
Ulnar collateral ligament insufficiency (gamekeeper's thumb). Rupture of the ulnar collateral ligament of the metacarpophalangeal (MCP) joint of the thumb can be acute or chronic.
1. History. A sudden valgus (abduction) stress applied to the MCP joint of the thumb results in partial or complete disruption of the ulnar collateral ligament. Falling with a ski pole in one's hand predisposes a skier to this injury.
2. Physical examination. The patient presents with a painful, swollen MCP joint of the thumb. An abduction stress (45 degrees of flexion) should reveal laxity in comparison with the normal side. The stress test may also be performed under local anesthesia in more severe cases.
3. Imaging. An avulsion fracture from the base of the proximal phalanx may be associated with the injury. A stress test with radiographs confirms the diagnosis. MRI can also aid in the diagnosis and confirm the presence of a Stener's lesion ( interposition of the adductor aponeurosis) between the free ends of the torn ulnar collateral ligament.
4. Treatment. Partial tears are treated nonoperatively with a molded thumb spica cast/splint. Complete tears are surgically repaired.

VI. Knee (ligamentous injuries)

Anatomy. Stability of the knee occurs in several planes: anteroposterior, medial, lateral, and rotational. Medial and lateral stability is imparted by the medial collateral ligament, lateral collateral ligament, and anterior cruciate ligament. Anteroposterior stability is imparted by the anterior cruciate and posterior cruciate ligaments. Other structures that contribute to knee stability include the knee joint capsule, menisci, and surrounding muscles.
1. The medial collateral ligament prevents medial opening of the knee with valgus stress. The anterior cruciate ligament and posterior capsule are secondary stabilizers against medial opening with valgus stress.
2. The lateral collateral ligament prevents lateral opening with varus stress. Secondary stabilizers against varus stress are the anterior cruciate ligament, posterior cruciate ligament, and popliteus muscle.
3. The anterior cruciate ligament prevents anterior displacement of the tibia relative to the femur. Secondary stabilizers are the medial meniscus and medial collateral ligament.
4. The posterior cruciate ligament prevents posterior displacement of the tibia relative to the femur. Secondary restraint to posterior displacement is imparted by the medial collateral ligament.
Classification of ligamentous injuries of the knee
1. Grade 1 (first-degree/mild) sprain. Characterized by local pain and swelling, without instability. Joint opening of 0 to 5 mm is found on examination. This injury is represented microscopically by a mild tear in the collagen fibers of the ligament; however, full continuity of the ligament is maintained.
2. Grade 2 (second-degree/moderate) sprain. Characterized by pain, swelling, and minimal to moderate instability. Joint opening of 6 to 10 mm is found on examination. A more substantial tear of collagen fibers is found, with some loss of continuity in the ligament.
3. Grade 3 (third-degree/severe) sprain. Characterized by swelling and marked instability. Joint opening of more than 10 mm is noted at examination. There is complete disruption of ligament continuity.
History
1. History of prior injury. An apparent acute tear of a ligament may actually represent the last of many recurrent episodes , each of which has damaged the involved ligament.
2. Mechanism of injury. Determine the nature of the knee injury. Valgus versus varus stress? Hyperflexion versus hyperextension injury? If a ski injury, ask the patient in which direction the ski pointed at the time of injury. If a football injury, determine how the foot was planted at the time of impact and the site and direction of the injury force.
3. Pain. Collateral ligament injuries are most painful at the site of damage. Cruciate ligament injury usually results in capsular distension (hemarthrosis) and vague knee pain.
4. Ability to continue sports. An athlete who, at the time of injury, could not resume activity as a result of pain or instability usually has more severe pathology than one who was able to continue.
5. A pop or snap immediately followed by swelling is characteristic of anterior cruciate ligament injuries.
6. Swelling that occurs immediately following injury usually indicates acute hemorrhage into the joint (hemarthrosis) and should raise suspicion of intraarticular fracture or cruciate ligament damage. Swelling that appears during the first 24 hours is more common in grade 1 or 2 collateral ligament injuries. Often, less joint swelling will occur in a grade 3 collateral ligament injury because the complete disruption allows joint fluid to escape into the periarticular soft tissues.
7. Giving way is typical in patients with clinically significant knee instability (i.e., anterior knee instability secondary to anterior cruciate ligament insufficiency). Locking or catching is more representative of meniscal pathology.
Physical examination
1. Inspection
  1. Gait. Patients with an acute ligamentous injury often walk with a limp, a flexed knee, or both.
  2. Swelling/effusion. Is there suprapatellar fullness in the standing or prone position? Is the joint taut with fluid?
  3. Ecchymosis. Collateral ligament injuries often show external signs of hemorrhage into soft tissue, which can present along the calf or ankle secondary to gravitational flow along muscle sheaths.
2. Range of motion is frequently limited secondary to pain. Lack of extension secondary to effusion should not be confused with the locked knee of meniscal etiology . Palpate for intraarticular effusion by compressing the suprapatellar pouch and ballottement of the patella.
3. Neurovascular status. A knee evaluation must include an assessment of popliteal and distal pulses as well as a thorough neurologic examination. The peroneal nerve is particularly susceptible to damage, especially in varus stress injuries that stretch the lateral structures of the knee.
4. Ligament stress testing. The patient should be supine and must be relaxed , as spasm and apprehension can obscure the diagnosis. The collateral ligaments should be tested with the knee in 0 and 30 degrees of flexion. At 30 degrees, the test is more specific for the collateral ligaments. During full extension, secondary stabilizers tighten to stabilize the joint; if the knee should open in extension, the injury is severe. Occasionally, 1% lidocaine injected into the site of pain or even general anesthesia may be needed to evaluate the knee properly.
  1. The medial collateral ligament stabilizes the joint against medial opening and thus protects against a valgus stress. To test this ligament, the limb is grasped with one hand while the femur is stabilized with the other, and a valgus stress is applied. Instability, if present, is more often sensed than seen. If the ligament has torn completely, the usual firm, abrupt end point will be absent. If the ligament is injured but not completely torn (grade 2), the end point from the remaining intact fibers is present; however, excursion may be increased.
  2. The lateral collateral ligament should be tested with a varus stress in the same manner. Additionally, the lateral collateral ligament can be palpated easily with the leg crossed in a figure 4 position.
  3. The anterior cruciate ligament is tested by translating the tibia anteriorly versus the femur.
    1. The Lachman test is easily performed with the knee at approximately 30 degrees of flexion by stabilizing the femur and distal thigh with one hand while an anterior force is applied to the back of the tibia. The examiner notes both the amount of excursion and the sense of end point. The absence of a normal crisp end point, even in the face of only minimal excursion, is usually indicative of an anterior cruciate ligament tear.
    2. The anterior drawer test is performed with the hip flexed 45 degrees and the knee flexed 90 degrees with the patient's foot flat on the table. The examiner sits on the foot and places the hands around the proximal tibia and, ensuring hamstring relaxation, applies an anterior force to the tibia, noting both the amount of excursion and quality of end point. This test is difficult to perform in the acute setting with associated knee swelling and is less accurate than the Lachman test.
    3. The pivot shift test notes anterior and rotational translation of the lateral tibial plateau with respect to the lateral femoral condyle. It is performed by having the patient relax fully and applying a valgus force to the knee with varying degrees of internal and external rotation of the tibia with respect to the femur. As the knee is brought from an extended to a flexed position, a sense of movement or jump takes places that in a chronic setting will reproduce the patient's sense of instability. Grading of the pivot shift is as follows: absent, 1+ (slide); 2+ (jump); 3+ (lock). It is very difficult to perform a pivot shift maneuver in an acute setting without sufficient anesthesia. Similarly, if a patient is apprehensive, it is a difficult maneuver to reproduce even in chronic settings.
  4. The posterior cruciate ligament is the primary restraint to posterior translation of the tibia with respect to the femur. The posterior drawer test is performed with the patient's hip flexed at 45 degrees and the knee flexed at 90 degrees. First visual inspection from the side may note less prominence of the tibia tubercle on the affected side with more prominence of the distal femoral condyles. On a posteriorly applied force to the tibia, the examiner will sense increased translation and absence of an end point. This is interpreted as a positive posterior drawer test.
    Note: When examiners perform a Lachman maneuver with the knee at 30 degrees of flexion and sense a large increase in amount of translation but a normal end point associated with a normal anterior cruciate ligament, they should suspect that they are really feeling a knee that has suffered a posterior cruciate ligament tear. What the examiner is actually doing is bringing the tibia back to its normal position under the femur.
  5. An evaluation of rotational stability includes an assessment of the popliteal tendon and lateral collateral ligament complex. These tests are performed at both 30 and 90 degrees of knee flexion. The patient lies prone and the degrees of external rotation of the affected and unaffected sides are compared. Increases in amount of external rotation are noted.
Diagnostic studies
1. Radiographs. Standard knee radiographic findings are usually negative but are useful to exclude a fracture. Avulsion fractures can sometimes be seen at ligamentous insertions (e.g., the tibial spine for anterior cruciate ligament injuries).
2. Stress radiographs. The joint opening is best viewed anteroposteriorly by applying mild stress.
3. Arthrograms are most useful for definite meniscal tears but may also demonstrate tears of the cruciate ligaments and more severe tears of the collateral ligaments. Leakage of dye from the joint usually indicates a complete collateral ligament disruption. This test is mostly of historical significance because of the ascendency of the MRI.
4. Magnetic resonance imaging has become increasingly accurate in the diagnosis of knee injuries and is easier for the patient to undergo in the acute setting. This is the study of choice for delineating soft-tissue injuries.
Differential diagnosis
1. Meniscus tear. The history of a twisting injury followed by swelling, locking, medial or lateral pain, and a limp suggests a collateral ligament injury; however, the Lachman or anterior drawer test findings are negative. Tenderness is usually along the joint line; patients are usually unable to perform a deep knee bend. The combination of meniscal damage with collateral or cruciate ligament injuries is common and should always be suspected when an acute knee injury is evaluated.
2. Patellofemoral subluxation or dislocation will often present as acute knee pain. Inherent abnormalities of the patellofemoral mechanism usually result in most patellofemoral injuries. These patients will complain of patellar apprehension and usually respond to physical therapy. However, surgical realignment of the extensor mechanism may be necessary in recurrent cases.
Treatment
1. Collateral ligament injuries without cruciate involvement are treated according to the degree of injury. However, most isolated injuries of the medial collateral ligament are treated in a conservative fashion.
  1. Grades 1 and 2. Protected weight- bearing based on the degree of the pain followed by early range of motion and rehabilitation of quadriceps musculature is indicated. Bracing is also used. MRI may be indicated to rule out concomitant meniscal pathology.
  2. Grade 3. These injuries seldom occur as an isolated event but still can be treated in a conservative manner. Attention should be directed at range of motion, as flexion contractures will easily develop in the immediate post-injury period in patients with significant medial collateral ligament pathology. Collateral hinge bracing is indicated. Early range of motion of the knee is instituted. If concomitant cruciate injury dictates surgical repair, surgery should be delayed until range of motion, specifically restoration of full extension, is obtained.
2. Cruciate ligament injury
  1. Injuries to the anterior cruciate ligament, when complete, usually lead to anterior instability in the knee. Whether patients are affected by that instability is dictated by their activity level and age. For a person whose life-style places high demands on the knee, surgical treatment is indicated. If a patient is willing to avoid activities that involve deceleration and cutting and jumping maneuvers, then anterior cruciate ligament injuries may be treated in a conservative fashion. MRI or arthroscopic investigation should be performed to rule out concomitant meniscal pathology.
  2. Injuries to the posterior cruciate ligament, although they leave the knee with a characteristic instability, are often tolerated on a functional basis and are treated in a conservative fashion, with attention directed primarily at restoration of quadriceps muscle power.
  3. Cruciate injuries that have an associated injury to the posterolateral structures of the knee ( popliteus, lateral collateral ligament, joint capsule ) will lead to functional disability even in day-to-day activities in sedentary persons. These injuries are also very difficult to treat when they become chronic. The best results are obtained with early surgical reconstruction of the cruciate ligaments and repair of the posterolateral corner.
Resumption of athletics. Patient should not be allowed to resume their usual athletic activities until the knee is stable, pain minimal, and the range of motion adequate. They should be able to run in place, hop on the affected leg without difficulty, run figure of 8 patterns in both directions, and start and stop quickly. Muscle strength should be 80% or more of that of the opposite extremity , and muscle atrophy should be less than 1 cm ( comparative circumference).

VII. Running injuries. Most running injuries to the musculoskeletal system are overuse-type problems that are typically preventable. A proper therapy program for any specific injury should include a conditioning regimen to prevent the recurrence of such injuries.

Etiology of injury
1. Biologic fatigue. Jogging or running requires repetitive motion that exposes the musculoskeletal system to severe stress. Even the most conditioned runner reaches a point of fatigue and biologic failure. Limitations and proper preparation are important in preventing running injuries.
2. Improper training. The once-a-week runner is the perfect candidate for a running injury. When muscle groups are inadequately conditioned, the repetitive forces associated with running can lead to injury. Excessive mileage, a sudden increase in mileage, and inadequate warm-up can lead to overuse injuries.
3. Anatomic variability. Patients with increased ligamentous laxity may be susceptible to sprains while running. The abnormal distribution of stresses on the feet of runners with flat feet or high arches makes them prone to particular problems. The likelihood of patellar problems is increased in a person with congenital abnormalities of the patellofemoral joint. The Q angle of the female hip may also predispose women to certain overuse running injuries.
History
1. Important questions
  1. Weekly mileage?
  2. Type of shoe worn ”any change in shoe type recently?
  3. Duration, location, and quality of pain?
Physical examination
1. Medical examination. A complete respiratory and cardiovascular examination is mandatory for all patients, particularly those over 40 years of age.
2. Musculoskeletal examination
  1. Observation for joint swelling, muscular atrophy, ecchymosis.
  2. Joint alignment
    1. In runners, it is important to evaluate the foot and ankle. Flat feet (pes planus) and high-arched feet (pes cavus) will be subjected to different stress patterns that predispose to different injuries. The knee examination should include an assessment of ligamentous stability and patellar tracking.
    2. Always watch the patient walk or run. Such activity will best demonstrate overall joint alignment in a functional, weight-bearing position.
  3. Palpation. Areas of maximum tenderness should be noted.
  4. Range of motion (active and passive) of the involved joint should be compared with that of the contralateral limb.
  5. Neurovascular status.
3. Type of shoe. If available, the runner's shoe should be examined.
  1. Fit. The shoe should be both wide and long enough to allow space for the toes. This reduces blistering and the formation of subungual hematomas. The tongue should be well- padded to prevent extensor tendinitis and irritation of the dorsum of the foot.
  2. Cushioning should be thick enough to reduce impact stresses.
  3. The heel should be wide, thick, and soft. Many runners use a heel-toe type of gait. Impact concentrates on the heel. Increasing the width of the heel increases the contact area and decreases the transmitted stresses.
  4. Rigidity is needed for support and flexibility for foot motion. The shoe should be flexible at the metatarsophalangeal region, where push-off occurs, but rigid at the arch (midfoot).
  5. The counter must be high enough to avoid injury to the Achilles tendon and long enough medially to prevent hindfoot valgus and counteract forefoot pronation.
Imaging studies
1. Radiographs. Many running injuries involve the soft tissues. However, stress and avulsion fractures, which occur quite frequently in runners, may be visualized on routine films. Joint alignment is best visualized with weight-bearing films .
2. Bone scans may afford the earliest diagnosis of a stress fracture, which may not be apparent on routine films for several weeks.
3. Magnetic resonance imaging and ultrasound can aid the clinician in chronic cases of refractory Achilles tendinitis (tendinosis).
Specific injuries
1. Foot and ankle problems
  1. Corns, calluses, and blisters. Painful, hypertrophic skin changes are caused by abnormal pressures and stresses. Pain is usually centered on the plantar surface of the metatarsal heads or the dorsum of the interphalangeal joints of toes. There are usually underlying structural foot deformities, including pes planus (flat foot) or pes cavus (high arch).
    1. Treatment is directed toward obtaining proper footwear, including padding to reduce stress on the area.
    2. Prevention. A gradual increase in running distance is recommended.
  2. Subungual hematoma is a traumatic hemorrhage under the nail bed with associated severe pain. Clotted blood under the nail causes it to lift off. Subungual hematoma is caused by poorly fitting footwear with a tight toe box. It is often noted in long-distance runners (marathon).
    1. Treatment. Therapy ranges from observation to decompression (placement of a hot wire through the nail to evacuate the hematoma). Removal of the nail may be needed secondarily.
    2. Prevention. Well-fitting footwear with sturdy, high, wide toe boxes will prevent the injury.
  3. Metatarsalgia is a syndrome of pain under the metatarsal heads, with the first to third most commonly involved. Pain usually follows an episode of prolonged running. Tenderness is noted directly under the involved metatarsal head, and an underlying structural deformity (pes cavus, hammertoes) may be present.
    1. Radiographs may reveal the underlying foot deformity.
    2. Treatment consists of a modification of footwear to include adequate cushioning and insertion of orthotics to redistribute weight from the metatarsal heads (metatarsal pad/bar).
    3. Prevention. The running gait should be changed to a heel-toe pattern.
  4. Stress fractures, which are fatigue fractures of bones secondary to repetitive stresses, are common in runners. There is a sudden or gradual onset of pain with swelling and tenderness at the site. The condition is often confused with shin splint. The tibial shaft and the first to third metatarsals are most commonly involved. A recent change in distance or running terrain is commonly reported.
    1. Radiographs may demonstrate periosteal callus 7 to 14 days after the appearance of symptoms, and the bone scan will demonstrate increased uptake within 3 to 5 days.
    2. Treatment consists of abstaining from running until symptoms cease . This is followed by a gradual increase in mileage. Stress fractures of the tarsal navicular and the base of the fifth metatarsal present unique problems and often require more aggressive forms of treatment.
    3. Prevention includes an adequate stretching program, avoidance of hard surfaces, no abrupt changes in running technique, and adequate footwear.
  5. Plantar fasciitis is inflammation of the plantar fascia, usually at its medial calcaneal origin. It is the most common cause of heel pain in runners. The patient usually experiences pain with the first few steps taken in the morning. There is usually tenderness at the anteromedial calcaneal margin, and tightness of the Achilles tendon may be present.
    1. Radiographs may reveal a calcaneal spur, but this is not diagnostic.
    2. Treatment
      1. Achilles tendon stretch program.
      2. Heel pads and/or heel cups.
      3. NSAIDs.
      4. Application of ice after running.
      5. Adhesive strapping.
      6. Injection of 20 to 40 mg of methylprednisolone acetate at the site of maximum tenderness.
      7. In rare cases, surgical release of the plantar fascia at the heel with removal of the spur may be needed.
    3. Prevention includes an adequate stretching program, avoidance of hard surfaces, no abrupt changes in running technique, and adequate footwear.
  6. Achilles tendinitis is a painful inflammation of the Achilles tendon resulting from repetitive stresses. Pain is present near the insertion of the Achilles tendon. Tenderness may be noted along the length of the tendon. Increased warmth and swelling are often present, and in severe cases, crepitus and a tendon nodule may develop.
    1. Predisposing factors include tightness of the Achilles tendon, cavus foot, functional talipes equinus, or a pronated foot secondary to forefoot or hindfoot varus or tibia vara. Running on hills and uneven terrain inflicts small cumulative tears in the tendon that produce the inflammatory response seen clinically.
    2. Treatment. Acute symptoms are treated by limitation of running, ice, and NSAIDs. A gradual return to running with a vigorous stretching program before and after running is essential. Local steroid injection may lead to tendon rupture. Rarely, surgical tenolysis or excision of a tender nodule is indicated.
    3. Prevention
      1. The runner should avoid hills and banked roads .
      2. The running shoe must have a flexible sole, a well-molded Achilles pad, a heel wedge at least 15 mm high, and a rigid heel counter.
      3. An aggressive Achilles tendon stretching program should be undertaken.
2. Leg problems
  1. Shin splint, characterized by pain along the inner distal two- thirds of the tibial shaft, is an overuse syndrome of either the posterior or anterior tibial muscle-tendon units.
    1. History. The patient experiences aching pain after running, usually in the posteromedial aspect of the leg; pain may be severe enough to prevent running.
    2. Physical examination. Tenderness is present along the involved muscle unit, and no neurovascular deficits are found on examination.
    3. Predisposing factors include poor conditioning, running on hard surfaces, and abnormal foot alignment, including hyperpronation.
    4. Treatment. Ice and rest are the initial measures. Alternating hot and cold soaks are helpful.
    5. Prevention includes avoidance of hard surfaces, a warm-up and stretching program, and, if needed, orthotic devices to prevent hyperpronation.
  2. Stress fracture. Tibia and fibula stress fractures present as sudden or gradual onset of pain in the leg. These fractures usually are a result of excessive training. Other etiologic factors include running too far and too fast, often with improper shoes on hard surfaces. A history of a recent increase in mileage is common. Point tenderness is noted at the site of fracture. The proximal posteromedial tibia and the distal fibula are two common sites.
    1. Radiographs. A stress fracture may not appear on a radiograph for 3 to 4 weeks after the onset of symptoms. Results of a bone scan will be positive within 3 to 5 days.
    2. The treatment of all stress fractures is the avoidance of running. Running is resumed gradually after the patient has been asymptomatic for at least 6 weeks and radiographic healing has occurred.
    3. Prevention includes gradual changes in running regimens, a vigorous stretching program, and orthotics for underlying structural foot problems.
  3. Exertional (chronic) compartment syndrome. This malady represents a common cause of leg pain in young persons. It is caused by a transient increase in muscular compartment pressure in response to exercise. The anterior and lateral compartments of the leg are most commonly involved.
    1. History. Increasing and progressive pain in the anterior or lateral aspect of the leg is reported with varying levels of exercise. Rest relieves symptoms. Numbness and paresthesias in the foot are common.
    2. Physical examination. Before exercise, findings are normal. Exercise causes the onset of symptoms. Occasionally, neurologic symptoms and signs become evident during the examination.
    3. Compartmental pressure measurement represents the mode by which a definitive diagnosis is made. An absolute value above 30 mm Hg or a relative increase in pressure of at least 20 mm Hg, after exercise, is usually diagnostic.
    4. Treatment. Conservative measure are always indicated initially (activity modification, orthotics, stretching). Surgical decompression (fasciotomy) of the compartment may be needed in refractory cases.
3. Thigh and hip problems
  1. Hamstring strain (pull) represents an injury to the musculotendinous unit. Symptoms may occur suddenly or develop slowly and are usually caused by inadequate stretching of these muscles before running activities. Patients with tight hamstrings are at an increased risk. Tenderness is present in the region of the hamstring in the back of the thigh or at the hamstring origin from the pelvis. Ecchymosis may be noted in more severe injuries.
    1. Radiographic findings are usually negative but may show an avulsion fracture or periosteal reaction at the origin of the hamstring.
    2. Treatment
      1. Acyte. Ice, rest, and modification of activity.
      2. Chronic. Stretching program, heat therapy, and ultrasound.
    3. Prevention includes a warm-up and stretching program.
  2. Stress fracture of the femoral neck presents as acute or insidious onset of pain in the hip or pelvis. Running accentuates the pain. Tenderness is usually present over the pubis or ischium in patients with pelvic stress fractures. Pain on hip motion (particularly internal rotation) may indicate a stress fracture of the femoral neck. The fracture occurs in novice runners or in runners whose training regimen is changed abruptly.
    1. Radiographs. A stress fracture may not appear on radiographs for 3 to 4 weeks after the onset of symptoms. Results of a bone scan will be positive within 3 to 5 days.
    2. Treatment consists of a reduction in activity and no weight bearing for a hip stress fracture, with a gradual return to normal activity after 6 to 8 weeks. In refractory cases, surgical fixation may be required to protect the femoral neck (pinning).
    3. Prevention includes proper training, a stretching program, avoidance of abrupt changes in training habits and assessment of bone density, if indicated.
  3. Iliotibial band friction syndrome is an overuse injury involving the iliotibial band and lateral femoral condyle. Pain is noted during knee flexion over the lateral condyle, where the friction occurs. Excessive iliotibial band tightness is prevalent in these patients; excessive foot pronation, genu varum, and tibial torsion may also be found. Climbing stairs and running (especially downhill) cause symptoms.
    1. Physical examination. Point tenderness is noted over the lateral condyle and sometimes the greater trochanter. Ober's test should be performed to assess iliotibial band tightness. Patients lie on their side with the unaffected limb flexed at the hip and down on the table, and the involved knee is flexed to 90 degrees and the hip extended. An excessively tight iliotibial band will prevent the affected limb/ knee from dropping below the horizontal plane between the two limbs.
    2. Radiographs. There are no significant findings.
    3. Treatment consists of rest, ice, NSAIDs, and stretching of the iliotibial band. Equipment change (i.e., shoes, bicycle seat) or foot orthotics may be helpful. More resistant cases may require ultrasound treatment or steroid injection. Surgical excision is performed only in the rarest of circumstances.
    4. Prevention consists of thorough iliotibial band stretching before activities.

Books@Ovid
Copyright 2000 by Lippincott Williams & Wilkins
Stephen A. Paget, M.D., Allan Gibofsky, M.D., J.D. and John F. Beary, III, M.D.
Manual of Rheumatology and Outpatient Orthopedic Disorders

-->