Common Sports Injuries: Part I
Common Sports Injuries: Part I
Author: Clayton F. Holmes, EdD, PT, ATC, Assistant Professor, University of Central Arkansas, Department of Physical Therapy, Little Rock, Ark.
Peer Reviewers: Brian Hardin, MD, Director of Adolescent Medicine, Adolescent Medicine Section, Arkansas Children’s Hospital, Little Rock, Ark; Stephen B. Gunther, MD, Assistant Professor of Clinical Orthopaedic Surgery, UCSF Department of Orthopaedic Surgery, San Francisco, Calif; and Robert C. Schenck, Jr., MD, Professor and Division Chief, Sports Medicine Section, University of New Mexico Health Science Center, Albuquerque, NM.
Editor’s Note—Each year, sports injuries account for approximately 500,000 visits to the doctor.1 Athletes who present as sports participants may be male or female, pre-adolescent, adolescent, or older. In the latter group, many of the injuries are musculoskeletal in nature. The joints most commonly involved are shoulder, ankle, and knee. This article, divided into two parts, describes the clinical presentation, examination, and intervention of several of the more common pathologies derived from sports-related injury.
Ankle Injuries
Boney Anatomy
The ankle joint is made up of three bones: the tibia, the fibula, and the talus. In addition, the talus sits on top of the calcaneus forming another joint called the talo-calcaneal or sub-talar joint.2
Ligaments
The lateral ligaments include the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) (see Figures 1 & 2).2,3
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The deltoid ligament resides medially. It is a triangular shaped ligament that fans out from the medial malleolus to the navicular, talus, and calcaneus.2 Other major ligament structures include the interosseus ligaments and the anterior and posterior tibio-fibular ligaments.3 Each of these ligaments plays major stabilizing roles relative to the ankle and foot.4 Musculotendinous structures include the tendons of the peroneus longus and brevis on the lateral aspect that traverse the lateral aspect of the ankle while the medial aspect of the ankle includes the tibialis posterior tendon, the flexor digitorum longus, and the flexor hallucis longus tendons.2
Biomechanics
Both the ankle joint proper and the sub-talar joint contribute to the motions of inversion and eversion. Other motions that occur at the ankle are plantar flexion and dorsiflexion. The distal fibula, or lateral malleolus, extends further distally than the medial malleolus does. In addition, the dome of the talus is wedge-shaped from front to back. The dome of the talus is wider posteriorly than it is anteriorly. This means that when the ankle moves into dorsiflexion, the bones are more congruent; therefore, the ankle is more stable. Converseley, when the ankle is in plantar flexion, it is less stable.
General Considerations: Ankle History and Physical Exam
Ankle injuries are the most common injuries that occur in the athletic arena.4,5 Common injuries include sprains, fractures, and tendon injuries.4 When performing a history of the ankle injury, it is critical to determine the mechanism of injury of the ankle.3-5 In most instances, the athlete will be able to recall this in some detail, but if the athlete cannot recall the mechanism of injury, there may have been an onlooker who could determine the mechanism of injury. This may be a teammate, coach, or athletic trainer.
General physical exam considerations include position of the foot—specifically, both the weight bearing and the non-weight bearing neutral position.5 A relatively normal gait can occur if the athlete can maintain the neutral position of the foot. In addition, this inspection should include the typical concern regarding swelling and ecchymosis. This swelling may be isolated over the sinus tarsi or it may be general edema. If this is a chronic sprain that has not been well taken care of, there may be pitting edema or general edema that is pitted when pressed. For example, this could occur if the athlete uses heat too soon after an acute injury.
The athlete should also be asked to perform active range of motion. This includes plantar flexion, dorsiflexion, inversion, and eversion. These motions are usually limited by swelling and pain.
A neurovascular exam including strength and sensation should be performed on all acute injuries. This includes evaluation of a distal pulse (tibialis posterior and/or dorsalis pedis) and an evaluation of dermatomes and myotomes. (For a discussion of myotomes, see Holmes CF. The preparticipation exam. Primary Care Reports 2000;6:189-202). Dermatomes are as follows: L-4 anterior medial lower leg, L-5 anterior lateral lower leg, S-1 lateral border of the foot, and S-2 is posterior leg (see Table 1).6 Myotomes should be checked for relative strength and dermatomes should be checked to determine if sensory input is intact to light touch.
| Table 1. Dermatomes of the Lower Extremity | |
| Nerve Root | Dermatome Description |
| L1 | lower back and groin |
| L2 | anterior thigh |
| L3 | anterior distal thigh and knee |
| L4 | medial lower leg |
| L5 | lateral lower leg |
| S1 | posterior lower leg to mid calf |
| S2 | posterior lower leg from mid calf up |
| Adapted from: Reese NB. Muscle and Sensory Testing. 1st ed. Philadelphia, Pa: WB Saunders Company; 1999. | |
Ankle Sprains
Different authors use different classifications of ankle sprains.4,5,7 In general, sprains are defined as damage to ligaments. Sprains are graded according to a cross-sectional microtrauma that occurs within each ligament. In other words, the anterior talofibular ligament could have a 1st degree (stretch), 2nd degree (partial tear), or a 3rd degree (complete tear) sprain (see Table 2).8 However, Nitz has described ankle sprains differently.8 In fact, he described 1st degree sprains as isolated anterior talofibular ligament sprains, 2nd degree sprains as those sprains involving other ligaments including the deltoid ligament, and 3rd degree sprains as those that involve tearing ATFL, deltoid ligaments, and involvement of ATFL and CFL. Perhaps a more appropriate classification is to modify the Nitz classification to include only the tibiofibular or high ankle sprain as the third degree. Regardless of the categorization scheme that is used, it is clear that anterior talofibular ligament involvement is present in the vast majority of ankle sprains.3-5,7 In addition, the lateral ligaments are involved 85% of the time.7
| Table 2. Nitz Categories of Ankle Sprains | |
| Grade 1 | lateral ligament involvement |
| Grade 2 | lateral and medial ligaments involved |
| Grade 3 | lateral, medial, and tibiofibular ligaments involved |
| Adapted from: Nitz AJ, et al. Nerve injury and grades II and III ankle sprains. Am J Sports Med 1985;13:177-182. | |
Grade I Ankle Sprains: History and Specific Physical Examination
The mechanism of injury of the classic lateral ankle sprain, primarily involving the anterior talofibular ligament, is plantar flexion with inversion.4,5,7 These sprains, while very common, can also be somewhat debilitating. In fact, if these sprains are not well taken care of, including a full course of rehabilitation, then reoccurrence of an ankle sprain is much more likely to occur.9
Inspection may indicate minimal or no swelling, which may be restricted to the sinus tarsi immediately overlying the ATF. The most common special tests used to evaluate the lateral ligaments include the anterior drawer test and the medial talar rock test. The anterior drawer test is performed specifically to evaluate the integrity of the anterior talofibular ligament. One hand stabilizes the distal leg while the other hand grasps the calcaneus and a force in an anterior direction from heel to toe is directed across the foot (see Figures 3 & 4).10 The medial talar rock is performed to test the integrity of the calcaneal fibular ligament. While performing this test, the foot is held in neutral with one hand while the other hand stabilizes the distal leg. The foot is then rocked into inversion, thus mimicking the mechanism of injury.5 Both of these tests are highly specific for a grade 1 ankle sprain.
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Grade I Ankle Sprain: Treatment/Rehabilitation
Treatment of grade 1 ankle sprains includes ice and rest acutely (mnemonic: R.I.C.E. = rest, ice, compression, elevation). The key to determining whether the athlete needs crutches is this: "Can the athlete ambulate with a normal gait?" If the athlete can ambulate with a normal gait, he or she may not need crutches or may just need one crutch (on the opposite side of the injury). If, however, the athlete has to walk with a limp, he or she needs crutches. However, with a grade 1 sprain, crutches should be only for relative rest. The athlete should practice a heel-toe gait while walking on crutches.11
As soon as the athlete can ambulate and has full range of motion without pain, then he or she is ready to begin aggressive rehabilitation. This is usually performed by a physical therapist and entails strengthening of possible structures that were injured including the peroneals with exercises such as resisted eversion using a thera-band. Perhaps, more importantly, this is a program of proprioceptive training. This begins in a static environment and then progresses to a dynamic environment. For example, a static environment could be nothing more than a single leg stance while the dynamic environment may include a BAPST board and/or a slide board, single-leg hops, etc. It is critical to note that the athlete is not prepared to go back to his or her activity until a rehabilitation program is completed. In this way, the athlete is less likely to have a recurrence of injury.4,5 Other therapeutic interventions that are common to the treatment of ankle sprains include early active range of motion exercises and kryokinetics. At a maximum, return to full activity occurs within 7-10 days.4
Ice should continue as the primary physical agent until swelling has stopped. Ice could then be replaced by contrast bath and then progressing to moist heat. This is also commonly followed by manual interventions including mobilization techniques, including low-grade mobilization techniques, to improve the nutritional status of the joint. As with any injury, morbidity is the primary consideration with regard to progression. For example, if pain and swelling increase in the ankle after the rehabilitation session, then obviously the rehabilitation was too aggressive. This rarely happens, particularly with grade 1 ankle sprains.
Finally, the vast majority of grade 1 ankle sprains should be protected for the remainder of the season. Common protections include taping by someone who is proficient in athletic taping (e.g., an athletic trainer or physical therapist). It is interesting to note that Wilkerson and Nitz reported that the U-shaped pad was extremely beneficial in decreasing swelling after a grade 1 ankle sprain.12 This pad should be put under tape.5 Another possible preventive measure is bracing instead of taping. Bracing has been shown to be as effective as taping in many instances, which may be due to proprioceptive feedback.13,14 Bracing has also been shown to be more cost-effective than taping when used.15
This rehabilitation is followed by a more functional rehabilitation in which the athlete mimics his or her sport and is slowly returned to that sport. This is the last phase of any rehabilitation in athletic injury. This rehabilitation should be directed by a physical therapist or an athletic trainer.4,7,9
Grade II Ankle Sprains: History and Specific Physical Exam
Grade 2 ankle sprains are those involving the deltoid ligament and take longer to heal.8 This is primarily because most feet pronate and the deltoid ligament bears more weight than the lateral ligaments of the ankle.4 Fortunately, these only constitute about 5% of ankle sprains.4
The mechanism of injury here is the opposite of the 1st degree sprain. That is, eversion is involved. When violent eversion occurs at the ankle, the fibula should be evaluated for fracture.
Inspection may reveal a more general swelling and obvious point tenderness over the deltoid ligament to palpation (medial joint line). In addition, a talar rock into eversion is often done to test the integrity of the deltoid ligament. This is performed in the same manner as inversion except the foot is rocked into eversion rather than inversion.10,16 Ecchymosis will appear much more frequently with grade 2 sprains and will overlie the medial joint.
Grade II Ankle Sprain: Treatment
Treatment is similar to that of the grade 1. The athlete may be out of action somewhere between two to four weeks (for grade 2 sprains).4
Grade III Ankle Sprains
Again, according to a modified Nitz classification, grade 3 sprains are syndesmosis sprains usually involving the anterior tib-fib ligament.8 Since the anterior tib-fib ligament traverses the talocural joint, it is much more difficult to heal. Specifically, every time the athlete bears weight, the talocural space is spread apart and this further traumatizes the tib-fib ligament.
History considerations include the mechanism of injury, which in this case is quite often a torsional stress. In other words, the talus rotates within the talocural joint. This injury usually involves ligaments other than the tib-fib ligament. It can include the interossseous ligament and the ligaments below the medial and lateral ligaments (ATF, CF, and deltoid).8
Inspection will be similar to that of a grade 2 sprain. There may be point tenderness over the anterior tib-fib ligament. In the acute phase, weight bearing and active range of motion will be painful. Strength should not be tested secondary to pain. The squeeze test, which is performed by compressing the fibula and the tibia at the mid-portion of the lower leg, is a common special test performed to determine if there is a syndesmosis sprain. Pain in an area of the anterior talocural joint may indicate a syndesmosis sprain.5
Radiographs
The Ottawa Ankle Rules have been put into place to determine the need for x-rays when ankle sprain is suspected to rule out fractures (see Table 3).3 Their usefulness has been demonstrated.3,17
| Table 3. Ottowa Ankle Rules for Radiographic Series Following Acute Ankle Injuries | |
| Ankle Radiographs are required only if the patient presents with pain in the malleolar zone and any of the following: | |
| • boney tenderness at tip of lateral malloelus | |
| • boney tenderness at tip of medial malloelus | |
| • presents with inability to bear weight | |
| Foot Radiographs are required only if patient has pain in the midfoot zone and any of the following: | |
| • boney tenderness at the base of the fifth metatarsel | |
| • boney tenderness at the navicular | |
| • presents with inability to bear weight | |
| Adapted from: Wexler RK. The injured ankle. Am Fam Physi- cian 1998;57(3):474-480. | |
Grade III Ankle Sprains: Treatment
There is some controversy with regard to immobilization of the grade 3 or high ankle sprain.4,5 Quite often, the use of an air cast in both severe grade 2 and grade sprains 3 is used. The athlete will definitely be nonweight bearing for a time with a grade 3 sprain to allow some healing to occur before weight bearing begins on the tib-fib ligament. Once the athlete gains full range of motion, rehabilitation can begin. This rehabilitation will follow much the same course as the grade 1. Obviously, the rehabilitation will be much slower and the ankle may take 4-8 weeks to heal.4
Tendonitis
History/Pathophysiology
Tendonitis about the ankle and foot is also a relatively common condition. Unlike ankle sprains that present with a history of trauma, tendonitis presents with a history of insidious onset. In other words, no specific mechanism of injury is recalled. This is not always true and acute tendonitis can occur. However, many times tendonitis occurs from chronic overuse. Table 4 summarizes common tendonitis sites, common causative factors, and signs and symptoms. The pathophysiology of tendonitis is relatively simple. Most tendons have a diminished blood supply relative to the rest of the contractile mechanism. In other words, poor blood supply can lead to an inability to recover from microtrauma. As that microtrauma accrues, at some point a critical mass of fibers is involved and the pain begins. As mentioned previously, this pain can slowly grow to a point to where many people have had tendonitis for several months before they seek help. Other common sites of tendonitis are the tibialis posterior, the tibialis anterior, and the paroneal tendon, but by far the most common is the achilles tendon.5
| Table 4. Tendonitis in the Lower Leg, Ankle, and Foot |
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| Common Sites | |
| • Achilles tendon just above its insertion into the calcaneous | |
| • Tibialis posterior just behind the medial malleolus | |
| • Tibialis anterior on the dorsum of the foot just under the extensor retinaculum | |
| • Peroneal tendon behind the lateral malleolus and at the insertion into the base of the fifth metatarsal |
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| Common Causative Factors | |
| • Faulty foot mechanics producing friction and compression between the tendon, sheath, and underlying boney struc- ture, or causing compression of the tendon against the shoe |
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| • Poor footwear that creates poor mechanics or is not fit properly |
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| • Training errors that include: | |
| Intensity too high, with poor work:rest ratio; | |
| Muscle fatigue leading to mechanical breakdown of foot function |
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| Poor training surface (dirty gym floor), sudden change from soft to hard or hard to soft (road camber change when running) |
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| Sudden changes in program such as adding hills, sprints, or distance |
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| Returning or progressing too quickly following an illness | |
| Poor flexibility in the gastrocnemius soleus muscle, which increases twist and whipping action of Achilles tendon because foot must increase pronation to increase dor- siflexion of the ankle joint in weight-bearing position; this in turn can produce chronic overstretching of Achilles tendon and result in microtears of tendon |
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| Trauma (direct blow) | |
| • Infection from an overlying cut or a penetrating wound into the tendon |
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| Signs and Symptoms | |
| • Pain with active movement, aggravated in weight bearing | |
| • Pain on passive stretching | |
| • Localized tenderness | |
| • Possible swelling and/or thickening in the tendon and peritendon tissues | |
| • May have "snowball crepitus" | |
| • Morning stiffness at site of lesion; this also occurs following any period of inactivity during the day when the part is not moved for 15-20 minutes or longer |
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| Adapted from: Athletic Injuries and Rehabilitation. Zachazewski JE, Quillen WS, eds. Philadelphia, Pa: WB Saunders Com- pany; 1996. |
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Specific Physical Examination
Achilles tendonitis is relatively common. Quite often, pain occurs just proximal to the insertion of the calcaneus. This could be due to faulty foot mechanics. Acutely, however, a heel lift should be used. It is also important to evaluate the athlete’s footwear. Many times, injuries such as tendonitis occur when shoes are "worn out." A list of training areas that cause tendonitis is included in Table 4. Signs and symptoms include pain with active movement. This pain may or may not be aggravated by weight bearing. There will be pain with passive stretching of the same tendon. Obviously, with palpation there will be localized tenderness. There may be swelling or thickening of the tendon in addition to some possible crepitious around the perry tendon tissues. Tendonitis pain is usually more prevalent in the early morning. As the day wears on, the blood supply of the tendon improves with motion and pain decreases.5
Treatment
Treatment for tendonitis about the ankle usually involves some form of orthotic fabrication and usually some form of heel lift. In addition, a course of rehabilitation should be undertaken usually by a physical therapist and/or athletic trainer.4,5,9 Initially, treatment should be relatively conservative. Obviously, changes in any training errors that have occurred should be a primary consideration. Lower leg alignment should also be evaluated. Typical rehabilitation usually includes some form of heat to improve blood flow, followed by active exercises within the tolerance of pain (exercise should not increase the pain). Common exercises include stretching of the tendon with contract-relax techniques that may include weight bearing on a trampoline progressing to weight bearing on ground. Functional rehabilitation will always include proprioceptive training such as static single-leg stance followed by balance in a dynamic environment (BAPST board, sliding board, etc.). The critical point of rehabilitation is the last phase of rehabilitation, which is the return to play. This should be done very slowly. Stress across the tendon should be increased slowly as activities of the sport should be mimicked in a lower load environment. This may be in water or on a trampoline. The athlete then progresses to a soft flat level surface, such as a grass field, and finally progresses to his or her athletic surface. These injuries generally occur in runners. The last surface that the athlete would return to would be a hard concrete surface. In fact, it is preferable that all athletes train on a softer surface.4,5,9
Part II of Common Sports Injuries will discuss knee injuries, including the anatomy, history, and physical exam; ACL tears, rehabilitation, the patella femoral joint, patellar tendonitis, radiographs, and the shoulder.
References
1. Powell JW, Barber-Foss KD. Injury patterns in selected high school sports: A review of the 1995-1997 seasons. Journal of Athletic Training 1999;34(3):277-284.
2. Netter FH. Atlas of Human Anatomy. 2nd ed. East Hanover, NJ: Novartis; 1997.
3. Wexler RK. The injured ankle. Am Fam Physician 1998;57(3): 474-480.
4. Funk DA, et al. Leg, ankle, and foot injuries. In: Schenck RC, ed. Athletic Training and Sports Medicine. 2nd ed. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1999.
5. Taunton J, et al. Leg, foot, and ankle injuries. In: Athletic Injuries and Rehabilitation. Zachazewski JE, Quillen WS, eds. Philadelphia, Pa: WB Saunders Company; 1996.
6. Reese NB. Muscle and Sensory Testing. 1st ed. Philadelphia, Pa: WB Saunders Company; 1999.
7. Pfeffer GB. Foot and ankle. In: Snider RK, ed. Essentials of Musculoskeletal Care. 1st ed. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1997.
8. Nitz AJ, et al. Nerve injury and grades II and III ankle sprains. Am J Sports Med 1985;13:177-182.
9. Anderson KJ, et al. Recurrent anterior subluxation of the ankle. J Bone Joint Surg Am 1952;34A:853-860.
10. Hoppenfeld S, Hutton R. Physical Examination of the Spine and the Extremities. New York, NY: Prentice Hall; 1976.
11. Holmes CF, Schenck RC. Applied principles in treatment and rehabilitation. In: Athletic Training and Sports Medicine. Schenck RC, ed. Chicago, Ill: American Academy of Orthopedic Surgeons; 1999:852-857.
12. Wilkerson GB, Nitz AJ. Dynamic ankle stability: Mechanical and neuromuscular interrelationships. J Sports Rehabil 1994;3:43-57.
13. Carroll MJ, Rijke AM, Perrin DH. Effect of the Swede-O ankle brace on talar tilt in subjects with unstable ankles. J Sports Rehabil 1993;2:261-267.
14. Feuerbach JW, Grabiner MD. Effect of the aircast on unilateral postural control: Amplitude and frequency variables. J Orthop Sports Phys Ther 1993;17:149-154.
15. Gross MT, et al. Comparison of support provided by ankle taping and semirigid orthosis. J Orthop Sports Phys Ther 1988;9:33-39.
16. Magee DJ, et al. Shoulder injuries. In: Zachazewski JE, Quillen WS, eds. Athletic Injuries and Rehabiliation. 1st ed. Philadelphia, Pa: WB Saunders; 1996.
17. Gilliagn B, et al. Application of the Ottawa Ankle Rules in children: A retrospective analysis. Pediatrics 1999;104(3):688.
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