Acute Management and Rehabilitation of Sport-Specific Musculoskeletal Injuries

ACUTE MANAGEMENT AND REHABILITATION OF SPORT-SPECIFIC MUSCULOSKELETAL INJURIES

Aaron M. Karlin and Kevin P. Murphy

Participation by children under the age of 12 in athletics and related recreational activities has increased greatly over the past decade (1). A casual notice of the growing number of children playing organized sports such as soccer, baseball, and hockey—or other non-organized athletic activities including skateboarding and pick-up basketball—after school or on a weekend illustrates this point. Because of this, the pediatric physiatrist needs to be well trained in basic sport-specific and musculoskeletal injuries related to these children and their activities. This chapter attempts to provide a basic discussion in this regard.

FOOTBALL

By far and away, there are a greater number and wider array of injuries incurred playing the sport of football than any other commonly played sport in the United States. This is due partly to football’s large number of participants as compared to other sports. This is especially true at the high school level where over 1 million of the 7.5 million high school athletes participating in competitive interscholastic sports annually are doing so by playing football. As a result, an increased frequency of exposures to contact/collision during games and practices alike contributes to football having one of the highest rates of injury of all competitive sports. Fortunately, injuries such as contusions, muscle strains, and minor joint sprains predominate. The gross majority of these injuries involve the lower extremities and most result in relatively few days lost from participation due to injury in comparison to more significant macrotrauma.

In the lower extremity of the football player, the knee is particularly vulnerable to injury—whether due to direct trauma from being tackled or colliding awkwardly with another player while the foot is planted in the ground bearing the athlete’s weight. An anterior cruciate ligament (ACL) injury frequently occurs with the latter of these two mechanisms. With the player’s foot planted, a forced twisting moment about the knee joint—often medial rotation—results in a partial or complete tear of the ACL. This can occur as an isolated injury without contact or, as is more frequently the case in football, resulting from direct contact to the knee. Oftentimes, this twisting force is coupled with a valgus force at the knee joint originating from an impact along the lateral aspect of the knee—either from the injured player being tackled at the knee or having the knee landed upon by another player with his or her foot planted. The injury may involve avulsion of the anterior tibial spine. It is not uncommon for the athlete to also incur a concomitant medial collateral ligament (MCL) sprain and/or meniscus injury. The valgus force at the knee effectively opens the medial aspect of the joint placing stress upon the MCL resulting in a partial tear or complete rupture. An associated medial meniscus tear may also occur due to its substance being contiguous with the fibers of the MCL. Concomitant injury to these three structures is commonly referred to as the “Unhappy Triad.” Commonly upon injury, the athlete describes a “popping” sensation about the knee with immediate onset of pain and swelling—the latter due to quick development of a hemarthrosis. On examination, the knee generally presents with instability noted by positive Lachman’s and anterior drawer testing. Initial treatment includes rest, ice, compression, and elevation (RICE) principles and a period of immobilization followed next by range of motion exercises.

Anterior cruciate ligament reconstructions in children, when performed, need to consider early closure of the distal, femoral, or proximal tibial physes or other growth disturbances with grafts that might cross the growth plate (2). Potential consequences of these growth disturbances include limb length discrepancy and angular deformities. Autogenous patellar tendon grafting appears to be the surgical choice, not to exclude other surgical considerations of autologous iliotibial graft or hamstring autograft or allograft. Over-the-top femoral graft placements (graft passed through the inter-condylar notch of the femur) have been reported by some authors with good success and efforts to spare excessive physeal penetration (3–5). Additional physeal-sparing reconstructions with minimal risk of growth arrest have been reported, with good success in the younger child (under 12) and adolescent (6).

An isolated MCL sprain, commonly the result of a valgus impact on the lateral aspect of the knee, is frequently able to be treated nonsurgically incorporating physical rehabilitation and, on occasion, bracing. An MCL injury is extra-articular in its location and therefore generally should not result in the development of a knee effusion. MCL sprains, as with all other ligament sprains, are graded on a scale of 1 to 3 with Grade 1 being a stretch injury to the ligament fibers without underlying instability; Grade 2 being a partial tear of the ligament fibers resulting in instability but with an end point remaining on exam; and Grade 3 being a full-thickness ligament tear with more marked instability and no end point felt on exam.

Meniscus tears can be isolated or associated with injury to other structures (eg, an MCL sprain). The mechanism of injury is similar to that seen with ACL injury and is associated with a twisting, shearing force at the knee with the foot planted. A small to moderate knee effusion is often present on exam. Meniscus provocative testing on exam, such as McMurray’s testing, is frequently positive. MRI of the knee is the best imaging modality for diagnosis of a meniscal tear. Treatment is generally conservative utilizing appropriate rehabilitation and, on occasion, bracing. Surgical intervention via arthroscopy and repair of the torn meniscus is reserved for cases not responding to conservative management or more severe tears. The report of a mechanical locking sensation about the knee by the athlete may represent a loose body within the joint resulting from the meniscal tear and would be another indication for surgery in order to facilitate its removal.

Patellar dislocation/subluxation is commonly seen resulting from a twisting movement about an extended knee joint with the foot planted, coupled with contraction of the quadriceps musculature. More than 90% of these dislocations occur laterally and frequently result in the rapid development of a knee swelling due to a hemarthrosis from tearing of the medial patellofemoral ligament and medial patellar retinaculum. Athletes at risk include those with anatomy contributing to excessive lateral patellar drive such as increased Q-angle, genu valgum, external tibial torsion, weak vastus medialis musculature, tight lateral retinaculum, and generalized ligamentous laxity. Acute management involves incorporation of RICE principles, anti-inflammatories, and a short period of knee immobilization with the joint in extension. Rehabilitation focuses upon strengthening of the patellar-stabilizing quadriceps musculature and is frequently augmented with the use of a patellar-tracking brace. Surgical intervention should be considered in those individuals with poor response to conservative rehabilitation or recurrent dislocation/subluxation.

Posterior cruciate ligament injury is relatively uncommon—especially in the pediatric and adolescent population. The mechanism of injury is a force directed anterior to posterior at the proximal tibia, which can be seen resulting from a fall directly onto one’s knees or as a classic “dashboard injury” associated with a motor vehicle collision. Conservative, nonsurgical management is the predominating care for this injury.

Another lower extremity injury common in football is the quadriceps contusion. While most contusions incurred playing football tend to be minor and short-lived in their duration, a contusion of the quadriceps muscle has the potential to be more severe. Hematoma formation about the anterior thigh is not uncommon and requires swift treatment in the acute stage including compression, ice, and positioning of the knee in the flexed position to encourage tamponade immediately after the injury. If left unchecked, the development of a large hematoma can lead to significant pain, restriction of the athlete’s range of motion, and weakness resulting in prolonged time away from sport. An additional risk, over time, is the development of myositis ossificans, calcification of a portion of the hematoma, which may require surgical intervention for removal. Therapeutic stretching and strengthening, as well as the use of ultrasound during physical therapy sessions can be helpful with reducing time away from sport.

A contusion of the iliac crest, known as a hip pointer, results from a direct blow to the bony pelvis. This can result from direct impact from a helmet when tackled or secondary to a hard fall to the ground. The affected area is often exquisitely tender due to underlying bony contusion as well as injury to the surrounding hip abductor and abdominal musculature. Initially, RICE principles and anti-inflammatories are utilized along with gentle range of motion stretches about the hip girdle. In more severe cases, avulsion injury to the iliac crest can occur resulting in longer time to return to play. Prevention is best achieved with the use of properly placed hip pads when playing.

In the foot, a turf toe injury results from a hyperextension injury to the metatarsophalangeal (MTP) joint of the great toe. More commonly seen in athletes playing on artificial turf, the hyperextension causes tearing of the joint capsule of the first MTP joint at the metatarsal neck. Radiographs are performed to rule out fracture of one of the sesamoid bones and stress views can demonstrate instability of the joint confirming the diagnosis. Early range of motion at the first MTP joint is extremely important though the use of a stiff shoe for pain relief may be necessary with ambulation. Turf toe injuries can be particularly troublesome and result in time away from sport ranging from 2 weeks to more than 2 months. Surgical referral is appropriate in those cases not responsive to conservative management.

While injuries to the upper extremities in football are less common than those affecting the lower extremities, many can result in significant time away from sports participation. Shoulder dislocation/subluxation is one of these injuries. This is generally unidirectional, occurring most commonly in the anterior direction, when the humerus is forced into extreme abduction (at or greater than 90 degrees), extension, and external rotation. This is often seen as the result of a defensive player reaching out laterally with a single arm to tackle an opposing player running past. The athlete is usually quite aware of the sensation of their shoulder “coming out of the socket.” Acutely, the player is unable to move the affected arm, prompting the need for immediate medical evaluation. Expedient reduction of the dislocated shoulder should be performed as long as there is no concern for fracture (eg, crepitus), and a number of safe methods for closed reduction are commonly utilized. Neurologic exam of the affected arm after reduction—to rule out injury to the musculocutaneous and axillary nerves among others—as well as radiographs to evaluate for the presence of bony injury are important. A Hill–Sacs deformity—an impaction fracture of the humeral head—and a bony Bankart lesion—fracture of the anterior–inferior glenoid—are two concerning bony injuries that may be associated with anterior glenohumeral dislocations and warrant orthopedic consultation. MRI of the injured shoulder is helpful for evaluation of injury to the surrounding soft tissue structures including the rotator cuff and the glenoid labrum. Initial management postreduction includes a period of immobilization—the duration of which is currently debated but can be up to 6 weeks. Rehabilitation of the dislocated/subluxed shoulder focuses upon strengthening of the rotator cuff musculature as well as scapular stabilizers with the aim of preventing recurrence. As with most other musculoskeletal injuries, athletes will begin a progressive return to the play program when they have shown full, pain-free range of motion about the shoulder as well as strength equal to the opposite uninjured joint. Surgical intervention is generally noted to be with good results in anterior, unilateral dislocations but is generally considered only after the athlete fails conservative management, has developed a history of frequent recurrence, or participates in a sport with a high risk for recurrence.

Other upper extremity joint dislocations/subluxations associated with football may occur at the elbow. Elbow dislocation involves complete slippage of the ulna posterior to the humerus and is usually associated with disruption of that elbow’s ulnar collateral ligament (UCL), radial collateral ligament, anterior capsule, and brachialis musculature. Elbow subluxation involves the trochlea being perched on the coronoid process. The gross majority of both of these injuries occur posteriorly and result from a fall onto an outstretched hand (FOOSH) injury. Associated elbow fractures—most commonly at the radial head—are not uncommon. Reduction should be done expediently, with care to monitor the neurovascular status of the distal extremity. After confirmation by radiograph of successful reduction, the arm is generally splinted in a position of 90 to 100 degrees of flexion with early protected range of motion initiated. Return to full athletics is generally at 8 to 10 weeks postinjury.

Additional shoulder region injuries commonly seen in football include acromioclavicular (AC) joint separations/sprains. These commonly occur resulting from direct trauma to the shoulder from tackling/blocking or from a fall with the arm adducted across the body. The force of this impact can disrupt the AC and/or coracoclavicular (CC) joint(s) while the more stable sternoclavicular (SC) joint remains intact. The athlete presents with focal tenderness to palpation overlying the AC joint as well as pain with terminal 20 to 30 degrees of glenohumeral abduction and cross-body adduction. This injury includes various presentations and severities with Type I (AC joint ligament sprain alone) and Type II (AC joint tear and CC joint sprain) being the most common. No step-off is usually palpated in either Type I or Type II. A Type III sprain involves complete tears of both the AC and CC joint ligaments, a step-off is usually palpated, and radiographs will show varying degrees of clavicular displacement superiorly. Type IV to VI injuries are associated with varying degrees and directions of displacement of the clavicle with associated injury to surrounding musculature, brachial plexus, or vasculature. Type I and II AC joint injuries are treated conservatively with RICE principles, anti-inflammatories, and sling immobilization initially. Progression to protected range of motion and strengthening of the rotator cuff and shoulder girdle musculature is next. Treatment of Type III injury is debated with respect to nonsurgical versus surgical approaches, with the latter being the default if the athlete fails conservative treatment after 3 to 6 months, the injury is to the dominant arm of a high-level throwing athlete (ie, a quarterback or pitcher), or the athelete desires to return to a contact/collision sport with a high risk for reinjury. Type IV to VI injuries warrant orthopedic consultation for operative management.

Fracture of the clavicle is one of the most common fractures of childhood usually resulting from a direct blow or a fall onto the clavicle or lateral aspect of the shoulder, or FOOSH. More than 80% of these fractures involve the middle third of the clavicle. These are generally treated with RICE principles, anti-inflammatory medications, and sling or figure-of-eight immobilization. Healing time varies dependent upon age, ranging from 3 to 4 weeks in young children to 6 weeks in adolescents and young adults. Both clinical healing—no pain with palpation and full, pain-free range of motion—and radiographic healing—bridging callous on x-ray—are required for consideration for return to athletics. An additional 2 weeks after this point is often incorporated when the athlete is returning to a contact/collision sport. Treatment of clavicle fractures involving the proximal and distal third of the bone is commonly referred to orthopedics for definitive management.

Neck injuries in football are not uncommon with cervical strain/sprain predominating. These often occur as the result of poor mechanics in tackling such as spearing and can put the athlete at risk for cervical cord injury. Icing the injured cervical paraspinal musculature and judicious use of anti-inflammatories are often adequate in the short term, with gentle range of motion exercises incorporated as well. Radiographs are necessitated when there is midline cervical spine tenderness or significant active range of motion restriction. A stinger or burner is the name given to the most common nerve injury in football and describes a brachial plexus neuropraxia. Compression or traction injury to the upper nerve roots of the brachial plexus results in this injury—often occurring after making a tackle associated with strong, lateral displacement of the neck. Painful, unilateral dysesthesias, radiating down into the upper extremity, are frequently coupled with weakness in the C5/C6 innervated musculature, most notably in the deltoid. This injury is commonly temporary—with return to play requiring return of pain-free range of motion and strength that is equal to the unaffected limb—though resolution of symptoms may vary from minutes to days. In more severe cases lasting weeks, electromyographic evaluation is warranted after symptoms have lasted greater than 3 weeks to assess for active healing via reinnervation. Transient quadriplegia is an uncommon presentation of injury to the cervical region and primarily associated with the sport of football. The player presents on the field with paralysis of the extremities that is self-resolving, frequently within minutes. Computed tomography (CT) scan or MRI of the neck frequently shows evidence of cervical canal stenosis. Future return to contact and collision sports for those with this injury is controversial owing to a perceived increased risk of more severe cervical cord injury (7–20).

BASEBALL AND SOFTBALL

Injuries to the upper extremities are the predominate causes of lost time from athletic participation in baseball and softball. These are most frequently overuse injuries related to the high amount of overhead throwing inherent in each of these sports—especially in baseball pitchers. The muscles of the rotator cuff—the supraspinatus, infraspinatus, subscapularis, and teres minor—are particularly vulnerable to injury due to the shoulder’s reliance upon them to maintain glenohumeral stability. Rotator cuff injury most commonly involves the supraspinatus muscle and may present as an acute strain or more subacute/chronic tendinosis. This frequently presents with complaint of pain with movement of the arm overhead such as throwing, lifting, or reaching for objects. Location of pain is variable about the shoulder and may be complicated by the presence of other concomitant shoulder pathology. Scapulothoracic dyskinesis—abnormal shifting in the typical position or motion of the scapula during coupled scapulohumeral movements—weakness in the scapular stabilizers and/or rotator cuff muscles, core weakness, and poor throwing mechanics are common contributing factors to the development of a rotator cuff injury. Pain persists with continued throwing or overhead activities and may be associated with reduced velocity or accuracy of throws. The shoulder exam reveals pain and, on occasion, weakness of the affected arm with isolated testing of injured rotator cuff muscle(s). Glenohumeral internal rotation deficit (GIRD) is also often present on exam—evidenced by increased glenohumeral external rotation range of motion coupled with decreased internal rotation range of motion in the painful throwing arm that is asymmetric in comparison to the opposite arm. Initial treatment often requires a period of relative rest from throwing and other overhead activities, icing of the shoulder, and anti-inflammatory use. This is followed by a rehabilitative protocol focusing upon strengthening of the rotator cuff and scapular stabilizers, addressing GIRD, if present, with specific stretching exercises, as well as evaluation of throwing mechanics and core strengthening. In the pediatric and adolescent athlete, rotator cuff impingement plays a less significant role in rotator cuff injury than in adults as anterior glenohumeral instability is the primary contributor. This occurs over time as the anterior shoulder capsule becomes repetitively stretched due to the mechanics of the overhead throwing motion allowing for increasing amounts of anterior–posterior translation of the humeral head within the glenohumeral joint. On exam, the athlete will commonly have discomfort with the anterior glenohumeral apprehension test followed by resolution of pain with a relocation maneuver preventing anterior translation of the humerus. The contribution of glenohumeral instability to rotator cuff injury underscores the need for glenohumeral stabilization exercises more than those focused upon stretching of the shoulder capsule and rotator cuff musculature. Final steps in return to play include completion of an interval throwing program that is commonly initiated once the athlete exhibits pain-free range of motion and strength equal to the opposite arm.

Instability of the glenohumeral joint may lend itself to the development of a glenoid labrum tear. This can be chronic in its presentation—or acute such as occurring secondary to a traumatic dislocation. Pain is frequently described as being located deep within the shoulder and may be associated with complaint of a clicking or popping sensation. The most common of these labral lesions in the throwing athlete is the superior labrum anterior and posterior lesion (SLAP). Tearing or fraying of the superior glenoid labrum at the attachment of the long head of the biceps is felt to occur due to excessive traction force applied to the site with the mechanics of overhead throwing—particularly deceleration of the arm. On exam, provocative tests of the labrum, such as O’Brien’s test, is commonly positive. Radiographs are generally normal and MRI with arthrogram is the imaging modality of choice to evaluate for glenoid labrum injury.

In the evaluation of the pediatric and adolescent athlete with shoulder pain, special care needs to be taken to keep in mind the presence of open physes—especially at the proximal humerus. Little leaguer’s shoulder (proximal humeral stress fracture) is an uncommon but potentially serious cause of shoulder pain in this population—as 80% of longitudinal growth of the humerus comes from its proximal physis. Presentation is often insidious and may last months before presentation to the physician. Tenderness to palpation over the proximal humerus is often present as can be pain at rest. Plain radiographs may show asymmetric widening of the proximal humeral physis in comparison to the opposite arm. Further evaluation with MRI of the shoulder can confirm the diagnosis, showing physeal edema. Treatment of little leaguer’s shoulder includes discontinuation of all overhead throwing for a minimum of 6 to 8 weeks followed by a rehabilitative protocol similar to that utilized with rotator cuff injury, and then initiation of an interval throwing program.

Elbow pain in the young throwing athlete is not uncommon with 20% of pitchers aged 10 to 14 complaining of elbow pain. The majority of injuries at the elbow, like those at the shoulder, are overuse injuries. Little leaguer’s elbow is a common term used to describe one of many chronic, overuse injuries about the elbow. Medial elbow pain is most common and related to muscular strain of the wrist flexor/pronator complex arising at the medial epicondyle. Valgus stress at the elbow during the throwing cycle results in opening of the medial joint line and places excessive stress upon these muscles. In this scenario, the skeletally immature athlete is at particular risk for development of traction apophysitis of the medial epicondyle. Pain is noted overlying the medial epicondyle and is worsened with resisted wrist flexion, pronation, and valgus stress of the elbow. Widening of the medial epicondylar apophysis as compared to the opposite arm may be noted on plain radiograph. MRI of the elbow will show edema at the apophysis. Initial treatment includes cessation of throwing upwards for 4 to 6 weeks—to prevent nonunion of the apophysis—as well as rehabilitation focusing upon strengthening and stretching of the wrist flexor–pronator musculature. Subsequent completion of a short-interval throwing program allows for return to play.

The repetitive valgus stress placed upon the elbow during the throwing cycle may result in a UCL sprain. The complaint of pain is generally greatest during the acceleration phase of throwing as valgus stress is highest. Over time, stretching or tearing of the UCL may develop, sometimes progressing to the point where the athlete describes feeling a sensation of the elbow joint opening when throwing. Tenderness over the UCL on exam is noted. Laxity of the UCL with valgus stress placed upon the elbow joint is not unusual. Plain radiographs generally are normal. MRI is most commonly utilized to assess for UCL injury. While partial tears can be treated with a period of rest from throwing and then a progressive rehabilitation program similar to other causes of medial elbow pain, full-thickness tears require surgical intervention if return to a throwing sport is desired. An uncommon complication of UCL sprain, ulnar neuritis, may occur due to the repetitive valgus stress at the elbow during the throwing cycle causing stretching of the ulnar nerve. Less frequently, subluxation of the ulnar nerve out of the cubital tunnel may occur. Dysesthesias along the lateral forearm into the fourth and fifth digits of the hand (ulnar nerve distribution) are often noted. Ulnar neuritis may be treated conservatively in most cases. If associated with a complete UCL tear, it is commonly repaired surgically as part of what is termed “Tommy John” surgery, fixing both injuries.

Lateral elbow pain in the throwing athlete results from lateral compressive forces to the elbow joint during the throwing cycle—primarily at the radiocapitellar joint. Osteochondritis dissecans (OCD) of the capitellum and Panner’s disease are two causes of lateral elbow pain in the young throwing athlete. Both are chronic in onset of pain, with throwing commonly worsening slowly over weeks to months. OCD tends to occur in early adolescence, at ages 13 to 16, and is frequently associated with loss of range of motion with decreased elbow extension as well as complaints such as joint locking or popping. Plain radiographs may show focal lesion development within the capitellum that may have progressed to becoming fragmented and displaced from the distal humerus. MRI of the elbow may show evidence of OCD of the capitellum before it is noted on radiographs. Orthopedic consultation is recommended, with treatment varying dependent upon the progression of the lesion and presence of displaced fragmentation of the capitellum. Contrasting with this, Panner’s disease does not tend to result in range of motion reduction or mechanical symptoms. Treatment consists of relative rest from throwing for a period of time, possible short-term immobilization, and serial radiographs to assess for bone healing over 6 to 12 weeks. Outcomes in athletes with Panner’s disease are generally good (15–17,21–27).

BASKETBALL AND VOLLEYBALL

Both acute traumatic and chronic overuse injuries to the knees and ankles are common to these sports owing to the frequent movements inherent in each sport including running, jumping, and sudden changes in direction on hard surfaces. Patellar tendinosis, also known as jumper’s knee, is the most common of the overuse injuries. It is caused by repetitive contraction of the knee extensor complex with the majority of the force overloading the patellar tendon. Activities such as jumping, stair climbing, running on an incline, and repetitive knee extensor resistive strength training can contribute to its onset. Lack of hamstring and quadriceps flexibility is a risk factor along with “doing too much too soon.” Pain on exam is often relegated to the patellar tendon—but may also involve the inferior pole of the patella—and can be marked, limiting the athlete’s ability to participate in sport. Treatment includes a period of relative rest from the inciting sport, icing, and anti-inflammatory use. This is then followed by stretching and protected strengthening of the lower extremity musculature. The use of a patellar strap to modify the fulcrum of force over the patellar tendon may be helpful.

Osgood–Schlatter disease is another common cause of knee pain in the pediatric and adolescent athlete. This traction apophysitis presents as point tenderness overlying the tibial tuberosity at the site of the insertion of the patellar tendon. Pain may be to a level of severity where athletic participation is limited—especially if associated with concomitant patellar tendinosis—though it often tends to be most painful whenever the inflamed tibial tuberosity is met with a direct impact. Conservative management incorporating relative rest, icing, anti-inflammatories, and protective padding is most common. Strengthening of the core and patellar-stabilizing musculature is helpful as well. Although the overall prognosis for Osgood–Schlatter is quite good, the course of resolution is frequently prolonged, taking months to years during adolescence. Sinding-Larsen–Johansen syndrome is similar to Osgood–Schlatter though occurring at the inferior patellar pole in contrast to the tibial tuberosity. Pain is located overlying this site which, on plain radiographs, gives the appearance of small avulsion-like fragmentation. Treatment is similar to Osgood–Schlatter—although the use of a patellar strap, as with patellar tendinosis, may provide additional benefit.

Similar in its presentation as a cause of anterior knee pain, plica syndrome involves inflammation in one of four synovial tissues about the knee joint originating from embryonic development. Commonly, these tissues are fully resorbed during fetal development but if this occurred incompletely they will remain. Inflammation of the plica is thought to result from direct trauma, repetitive stress/overuse, meniscal tears, or other knee pathology. Pain occurs with repetitive flexion of the knee and the plica rubbing against one of the bony structures about the knee—with the medial plica abrading the medial femoral condyle as the most commonly proposed site—though this explanation is controversial. Tenderness on exam over the area of the inflamed plica as well as palpation of the structure itself is common. RICE principles, anti-inflammatory use, and stretching/strengthening of the knee extensor/flexor mechanism may be helpful. In reticent cases, surgical removal of the painful plica is performed.

Finger sprains and fractures are not uncommon in basketball and volleyball owing to the frequent passing, catching, handling, and attempted blocking of the ball to varying degrees in each sport. These can generally be treated with minimal periods of immobilization or simply buddy taping dependent upon the location and severity of the injury. Contrasting with this, a mallet finger involves injury to the extensor digitorum tendon of the finger usually resulting from a hyperflexion injury at the distal interphalangeal (DIP) joint. This commonly occurs when the athlete catches a basketball awkwardly and an extended finger becomes jammed, forced into hyperflexion disrupting the distal extensor tendon. The athlete will usually present with an inability to fully extend at the DIP joint of the injured finger and tenderness over the dorsum of the DIP joint. Plain radiographs are performed to assess for the presence of an avulsion fracture which, if substantial, may require surgical fixation. Otherwise, conservative treatment with continuous splinting of the injured finger in hyperextension at the DIP joint for a minimum of 6 weeks is commonly performed (13,14,20,28).

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