Assessment

Consider both intrinsic and extrinsic factors.

Intrinsic factors encompass physical, physiological and psychological aspects of an individual that may contribute to injury (Table 22.1). Note that physical development is often different in athletes, and muscle development or joint range of motion may be asymmetrical depending upon the sport (e.g. tennis). Similarly, what is normal in the general population may be abnormal for an athlete; for example, flexibility that is typical of the general population would be considered inadequate in a gymnast.

Extrinsic factors play a significant role in the development of injury. Doing ‘too much, too soon, too often’ is a common factor. Consider other factors such as equipment errors, environmental conditions and hard/uneven surfaces.

A central concept in the development of an injury is a lack of functional control. This relates to the fine balance that exists between optimal mobility of the body or body area and its stability.

History – Take a history of the injury, training and competing habits, the potential role of other extrinsic factors, previous injury history and other medical issues. The mechanism of injury is important in elucidating the diagnosis, as it will implicate the structures involved and the severity of the injury.

Pain is typically the cardinal presenting symptom so a careful pain history should be recorded: the character of the pain, its site(s), radiation, timing of onset and subsequent temporal pattern, aggravating and relieving features and associated symptoms. The degree of swelling and its rapidity of onset after injury frequently correlate with the severity of injury. Instability or a feeling of ‘pre‐instability’ are highly relevant in sport and may indicate a true structural deficit or a lack of neuromuscular control. Clicking and clunking of a joint is relevant particularly if new or painful. Neurological symptoms may be present and may indicate a true neurological deficit or, more frequently, neural irritation in association with a chronic soft tissue injury.

Establish also the treatments used to date, medications (including supplements) and a general medical background. Always consider the possibility of an underlying medical complaint, such as a tumour or inflammatory arthritis/enthesitis. Note also that bone health issues are not uncommon in both male and female athletes.

The age of the patient is also very important: children have fragile skeletons with vulnerable growth plates and an increased risk of avulsion injuries. The senior population have an increased susceptibility to soft tissue injuries and arthritis and higher rates of co‐morbidities that may influence the injury, and are slower to respond to treatment.

Examination – Examination commences with a general examination, in particular looking for stigmata of other disease, hypermobility and assessment of the spine, since dysfunction here can contribute to injury. Functional movements and core control are important. Assessment for asymmetry of muscle development and flexibility is important but must be interpreted carefully.

Regional assessment of the injury follows the usual strategy of ‘look, feel, move, and special tests’. Identification of the site(s) of tenderness, swelling, instability and neurovascular status follows.

The clinician should seek to evaluate the patient dynamically, as at times only this will reproduce symptoms and functional control is so vitally important in injury causation and management. Part of this functional assessment is gait analysis (Figure 22.2).

Investigations – Investigations, in particular imaging, are frequently required in the assessment of the injury, but should be requested only after a clinical diagnosis is made, and interpreted carefully. No imaging is foolproof and it is vital to request the correct test for the suspected injury. Athletes may commonly have abnormalities on imaging that are not relevant to the clinical complaint.

Imaging includes plain X‐rays, diagnostic ultrasound, MRI, CT and isotope bone scans. Plain X‐rays assess for fractures, myositis ossificans, loose bodies and significant underlying joint damage but are not sensitive to early stress injuries, nor to many articular complaints. Stress views may be necessary to assess for instability. Diagnostic ultrasound demonstrates even subtle soft tissue pathologies and impingements and allows dynamic assessment of the joint in question. MRI provides further information of the surrounding anatomy, bone oedema, bone stress syndromes and some soft tissue injuries (Figure 22.3). MR arthrography may be necessary to evaluate the labra of shoulder and hip most accurately. CT is useful to detect loose bodies and to evaluate bone healing. SPECT may be used to evaluate bone stress injuries in particular. Serology for underlying medical complaints may be necessary.

Compartment studies measure intramuscular pressures before, during and after exercise, and are used to evaluate individuals with possible chronic exertional compartment syndromes.

Where there is a question about bone health in those with recurrent stress fractures, other investigations, such as DEXA scanning, may be warranted. The sites of low bone density in athletes may differ from the general population in view of the different patterns of skeletal loading; scanning of sites such as the forearm is often necessary.

Management (Box 22.1)

Management of sports injuries commences with an accurate diagnosis and identification of all the contributing factors. Education and counselling in relation to the injury, and discussion and agreement on an appropriate management strategy are vital. Ensuring the athlete has a clear understanding of the injury, its implications and treatment will enhance appropriate levels of compliance. Clear goals need to be set, and reviewed regularly.