The intent of this chapter is to provide a brief overview of common musculoskeletal injuries encountered during sports. For an in-depth review please refer to Chapters 29, 30, and 31.
The Centers for Disease Control and Prevention estimated that 7 million people in the United States received care for sports-related injuries. Based on a national database, the incidence was 25.9 per 1,000 persons.1 The age group with the highest injury rate was children ages 5 to 14 (59.3 per 1,000 persons). Males had twice the rate as females, and basketball was the most commonly reported activity during which an injury occurred. Strains and sprains were the most common type of injury, with fractures being second most common.
One of the key diagnostic tools for musculoskeletal complaints is the patient history. The mechanism of injury should be obtained in detail. Bystander history can be a useful surrogate if the athlete does not specifically recall the incident. Demographic information such as sex, age, and patient characteristics (e.g. handedness, occupation, past injuries, and baseline activity levels) are additional clues that may guide the differential.
Physical exam tests have variable sensitivity and specificity for diagnosis. Recognizing the underlying anatomy of the pain or injury location is important, as it will guide the exam. In many instances, examination of the contralateral body part can provide a “normal” version for comparison of the patient’s injured side. The theory of the kinetic chain needs to be considered: pain or injury in one area could actually be caused by pathology in another location (i.e., scapular dyskinesia leads to elbow pain in baseball pitchers).2
Imaging and laboratory testing can aid in diagnosis. Advanced imaging such as magnetic resonance imaging (MRI) is not always necessary, nor may it pinpoint the cause of pain in all cases since many asymptomatic individuals may have abnormal imaging findings.3
Physical therapy is a common management option for the majority of sports-related injuries. The goal of therapy is to directly strengthen the injured area or to affect areas that indirectly influence the region of injury or pain and eventually restore athletic function. Intraarticular, bursal, or tendon sheath injections are another therapeutic route. Surgical options should be reserved for patients who have failed conservative treatment modalities.
An estimated 1.6 to 3.8 million people experience a sports-related traumatic brain injury every year.4 The most commonly reported symptoms of concussion are headache, dizziness, and confusion.5 Loss of consciousness, which historically has been identified as pathognomonic for this injury, does not occur in all cases.
Concussion is a clinical diagnosis, based on history and mechanism of injury. Imaging has been found to be overused and without red flag signs of fracture (postauricular bleeding, raccoon eyes, hemotympanum) or intracerebral bleeding (mental status changes, focal neurologic deficits, persistent vomiting) likely does not add to the diagnosis.6–8
The majority of individuals have symptoms for 1 to 4 weeks after the incident.9 Follow-up care involves symptom monitoring using validated scales (e.g., Standardized Concussion Assessment Tool [SCAT]) and vestibular testing. Neurocognitive tests (e.g., Impact) can aid in monitoring objective signs of concussion but should be used in tandem with clinical symptoms and exam to make return-to-play decisions.
Currently all 50 states have concussion legislation specifically in regard to youth athletes, and now many professional sports leagues require time off from playing once an athlete has been diagnosed with a concussion.10 Return to play requires clearance from a provider, with gradual return to play involving monitoring for return of symptoms during the increase in physical activity. Recently, monitoring symptoms and vital signs during low-impact aerobic activity has been used to help progress players with postconcussive syndrome (symptoms >3 weeks despite rest).11 Early aerobic activity is currently being investigated as a potential tool to hasten recovery in teen athletes with concussion.12
Brachial neuropraxia (pain and/or paresthesia with or without motor weakness resulting from hard contact to the head and/or shoulders) is a common reversible injury experienced by football players. Weakness often occurs in the C5–C6 nerve root distribution. An incidence rate of 26% was found in one college-level football team.13 A blow to the shoulder was the most common cause in this study.
Diagnosis requires resolution of symptoms, usually within 24 hours of onset. Persistent or worsening symptoms or initial weakness suggests a different diagnosis, such as cervical disc herniation, spinal cord injury, or cervical fracture. Further evaluation includes cervical imaging (computerized tomography [CT] or MRI); such imaging is required for bilateral symptoms or symptoms that do not resolve after several hours.14
Management for most cases is conservative and incorporates focused physical therapy and removal from play until the symptoms have resolved. Most symptoms resolve in 10 to 15 minutes, but may take up to 2 days.15
Athletes must be asymptomatic prior to return to play with full range of motion and strength in their extremities.16
Neck pain can have an insidious onset from ergonomic stressors and muscular imbalances, or it can have acute onset from trauma such as whiplash secondary to a motor vehicle accident. Other etiologies include osteoarthritis or neoplasm. Occupational and activity history should be obtained. Pain can radiate into the upper extremities, and neurologic symptoms such as weakness, paresthesias, and neuralgias can also be found distally with radiculopathy.
Patients should be questioned about symptoms of paresthesia or weakness in the upper extremities in order to assess any neural component/involvement. A comprehensive physical examination is critical to rule out signs of myelopathy or radiculopathy. This includes complete neurologic examination, which includes motor testing, active root tension signs (e.g., Spurling’s test), Hoffman’s sign, and reflexes.
Plain films are not required initially if no red flag symptoms exist (i.e., significant trauma, fever, history of intravenous drug use, weight loss).17 Anteroposterior (AP) and lateral views evaluate for spondylolisthesis, compression, osteophytes, and disc space narrowing. Flexion and extension views are not always necessary or helpful, particularly in nontraumatic cases, but may add value in ruling out spinal instability.17 This is particularly helpful in cases of trauma and whiplash.18 If radiculopathy or myelopathy are present, then an MRI should be considered to determine the integrity of the spinal canal, discs, nerve roots, and spinal cord.19 Range of motion of the neck declines with aging, and this should be taken into consideration during examination.
Choice of management depends on the etiology of injury. For muscular causes, stretching, massage, anti-inflammatories, and muscle relaxants are helpful, although evidence is not robust that these are more helpful than no treatment.20 In acute injuries such as strains and spasms, time is often just as helpful as the treatment modalities. Nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants may be used for a short term if no contraindications exist. In patients with whiplash, there is evidence to support early mobilization and to avoid cervical collars.17 Patients with stable fractures, including spinous process fractures, require a cervical collar for at least 8 to 12 weeks; additionally they should be pain free and have a normal neurologic examination. Patients with unstable fractures should undergo advanced imaging and neurosurgical evaluation.21 There is no high-level evidence that supports the use of opiates for a long term in this population. For patients unresponsive to therapies, interventional pain management may be considered, which includes epidural steroid injections.
Return to play depends on the injury. Patients with a soft tissue injury or muscular strain may return to play following resolution of symptoms and after instability and fracture have been safely ruled out. Patients with cervical fractures will need to wait up to 4 months until they can safely return.21 Patients with atlantoaxial fusion, instability, or spear tackler’s spine are absolute contraindications for return to contact sports.22
There are numerous diagnostic tests for shoulder pain, but few have high specificity for distinct diagnoses.22 Occupational history, as previously mentioned, is often germane for clinical diagnosis.
This is usually a traumatic insult, a common example being a cyclist’s fall. Patients will complain of superolateral shoulder pain and usually are reluctant to move their arm. The differential includes glenohumeral dislocation/subluxation, clavicle or humerus fracture, and rotator cuff tearing.23
Diagnosis is established from history, physical exam findings (pain with AC palpation, positive cross-arm test), and plain films that may show widening of the joint (Fig. 28–1). Bilateral AP radiographs are helpful in determining the degree of separation. Axillary and Zanca views are helpful for determining anterior or posterior displacement. Weighted films are no longer recommended.24 The scarf test (horizontal adduction) will cause pain in the AC area.
Figure 28–1
The anatomic basis (left), clinical appearance (middle, with arrow pointing to the AC joint deformity), and x-ray findings seen with a type II AC joint separation. (Reproduced with permission from The Shoulder. In: Parks E,eds. Practical Office Orthopedics, New York, NY: McGraw-Hill; 2018.)
There are different grades of AC separations, some of which may require surgery. In most cases, rest and a sling are adequate.25 Surgery is indicated for injuries in which there is coracoclavicular space widening of >100% compared to the uninjured side, although this is an area of active debate.
Return to play is based on resumption of baseline range of motion. Time out of sport varies by the degree of injury. Conservative treatment of type III injuries has been reported successful after 12 weeks.26 A corticosteroid injection may be beneficial for patients with persistent pain.
This is one of the most common traumatic injuries experienced in athletes. The most common mechanism is direct trauma to the shoulder. Common signs and symptoms include inability to move the arm in forward flexion and visible malformation in the clavicle area.27
AP and clavicle view plain radiographs are usually confirmatory. Axillary and Zanca views may assist in the diagnosis of displacement or other coexisting injuries such as scapular and humeral fracture28 (Fig. 28–2).
Management includes use of a sling and rest. Any break in skin integrity or skin bruising in the area of the fracture must raise the question of an open fracture and needs surgical referral. A figure of 8 brace has not been found to offer additional benefit as compared to a regular sling and in many cases is less comfortable to wear.29 Most midshaft fractures do not need surgery, as nonunion is rare. Lateral fractures, especially those with AC joint involvement, have a higher rate of nonunion.30
Return to play is based on improvement in the patient’s symptoms, evidence of radiologic healing, and return to baseline range of motion and strength. Most fractures show adequate healing in 4 to 6 weeks, and patients can begin physical therapy for strengthening and range of motion. Full-contact activities can usually be resumed in 9 to 12 weeks.31
Rotator cuff injuries can be acute, chronic, or a combination of the two. Acute tears commonly result from a traumatic incident or a sudden motion. Chronic tears occur more insidiously, and it may be difficult to identify a specific incident. Patients will complain of pain in the shoulder area; it can be generalized or focused in a specific region (posterior, anterior). Weakness on physical exam is evidence of loss of active range of motion, and decreased pressure to resistance signifies more significant tearing. Lag signs such as the lift-off and belly tests (subscapularis), empty-can or drop-arm (supraspinatus), external rotation lag sign (infraspinatus), or horn-blower test (teres minor) may be helpful physical exam tests to assess for severe tendon ruptures (Fig. 28–3).32
Figure 28–3
Rotator cuff and rotator cuff tears. (A) The anatomy of the rotator cuff. (B-E) Partial-thickness tears do not extend through the whole thickness of the tendon and are classified as articular-surface (B), bursal-surface (C), and interstitial (D) tears. Low-grade partial-thickness tears involve less than 50% of the tendon; moderate-grade partial-thickness tears involve about 50% of the tendon thickness; and high-grade partial-thickness tears involve more than 50% of the tendon thickness. (E) Full-thickness tears extend from the bursal surface to the articular surface of the tendon and can be complete (involving the whole width of the tendon) or incomplete. Full-thickness tears that involve more than one tendon are called massive tears. The degree of tendon retraction (r) is quantified by how far the torn tendon is from its normal attachment. (Reproduced with permission from Amini B, Metwalli ZA. Musculoskeletal. In: Elsayes KM, Oldham SA, eds. Introduction to Diagnostic Radiology, New York, NY: McGraw-Hill; 2014.)
Practitioners must be aware that cuff tears are a common baseline finding in older individuals on exam and on imaging studies, even when they are asymptomatic.33 In an acute tear, the main complaint is weakness, and MRI or bedside ultrasound is often useful in confirming the diagnosis.
Surgery is strongly considered in acute traumatic rotator cuff tears. Atrophy of shoulder girdle musculature on MRI often points toward a chronic etiology, and surgical outcomes are less favorable.34 In acute injuries that involve muscle weakness in young athletes, surgery should be considered in the early stages of management if conservative therapy does not work and the athlete cannot return to the prior level of play.35
Physical therapy should be attempted first in chronic rotator cuff tears, as many individuals have improvement in motion and a decrease in pain with therapy alone. Therapy must address any underlying weakness of the scapular stabilizing muscles, as scapular dyskinesia can lead to cuff impingement biomechanically.36 Corticosteroid injections can be considered for continued pain.
Of note, this is an uncommon injury in the pediatric population. Growth plate fracture or stress reactions are much more common.
Return to play is based on improvement in the patient’s symptoms and return to baseline range of motion and strength. Time to return to play depends on severity of injury and operative versus nonoperative treatment. Rehabilitation following rotator cuff repair typically lasts at least 4 to 6 months, and functional return to play may take as long at 18 months depending on sport and level of play.37
Adhesive capsulitis, or “frozen shoulder,” is a common cause of shoulder pain. Subpopulations known to be affected at higher rates include females and individuals with diabetes or thyroid conditions. Common symptoms are motion restriction and shoulder pain. Symptoms typically have a “freezing” phase of 3 to 4 months, then pain improves and motion begins to slowly return in most cases. A portion of these patients does not improve clinically and eventually develops disability.
Plain films are often normal in patients. MRI images can show thickening of the soft tissues surrounding the shoulder capsule.
It is a self-resolving condition in some cases. Treatments include aggressive physical therapy with an emphasis on range of motion, percutaneous capsular dilation procedures (i.e., Brisement procedure) or surgical capsular release. There is limited high-level evidence that these interventions lessen the overall duration.38 Corticosteroid injections can often help symptomatically with pain. There is a 30% likelihood that the contralateral side will be affected.39
Return to play is based on improvement in the patient’s symptoms and return to baseline range of motion and strength. The entire time frame of the condition can range from 12 to 18 months to 3 to 4 years.40,41 Specific populations such as diabetics are known to have a longer course.42 Patient counseling regarding the long duration of the condition is essential.
The most common cause of shoulder instability is a result of a dislocation from a traumatic event. Genetic conditions such as Ehlers-Danlos syndrome may also intrinsically predispose individuals to ligamentous laxity. There are three different categories of instability: anterior, posterior, and inferior; patients may have a combination of more than one. Subluxation differs from dislocation, in that the reduction is spontaneous in subluxation. In contrast, a dislocated shoulder needs to be reduced by another individual. Physical exam findings include motion hesitancy and laxity, particularly if the athlete has had more than one episode. A positive anterior apprehension test (the shoulder abducted and eternally rotated) results when the athlete feels “apprehension” that they will dislocate with examiner passive external rotation. The posterior jerk test may show laxity with posterior force, and inferior laxity can be elicited with the sulcus sign (Fig. 28–4).41
Figure 28–4
The apprehension test for anterior instability. (Reproduced with permission from McMahon PJ, Kaplan LD, Popkin CA. Chapter 3. Sports Medicine. In: Skinner HB, McMahon PJ, eds. Current Diagnosis & Treatment in Orthopedics, 5e New York, NY: McGraw-Hill; 2014.)
Axillary, Stryker-notch, and West Point views can be helpful to assess for Bankhart and Hill-Sachs lesions.43 Plain films are necessary to display the appropriate relocation after reduction.
Initial management following a dislocation or subluxation is rest and sling bracing. Some evidence points toward improved outcomes with bracing in external rotation; however, this is controversial, and patients typically do not tolerate the position well.44 Physical therapy is aimed at strengthening the scapular-stabilizing musculature. Maximizing the function of these muscles may decrease symptoms and recurrence rates by accounting for the lack of labral integrity. Surgery to tighten the capsule is often helpful for cases in which dislocation or subluxation continues in spite of appropriate therapy being utilized or full strength has not returned after conservative therapy.
Once an athlete has experienced a dislocation, they have a higher risk of recurrence, as the integrity of the labrum is often damaged during the initial insult and therefore its ability to stabilize the shoulder is diminished.45 A Sully shoulder brace may offer additional support during sporting contests. Athletes should have normal range of motion and strength prior to being cleared to return to sport.
Labral pathology is common in baseball players and overhead athletes, as it allows them to have greater potential external rotation. Repeated injury may lead to damage. Acute pathology can occur as a result of a fall or trauma. Labral tear must be also considered whenever the biceps tendon (as its origin of the long head is within the labrum) or rotator cuff is injured. Common symptoms include pain, clicking or locking, and loss of range of motion.46 One of the more specific exam tests for this diagnosis is the Mayo shear test, as well as the O’Brien test.47
The imaging study of choice is an MRI arthrogram, which provides for more specific information compared to a noncontrast MRI.48
Surgery may be necessary for persistent symptoms, but physical therapy can be attempted as an initial conservative therapy.
Athletes should have normal range of motion and strength prior to being cleared to return to sport. Time to return to play following surgical repair averages about 12 months.49
Throwing sports like baseball and javelin have high rates of medial elbow pathology. Important patient history information includes whether there has been a change in training load or technique. Athletes will complain of medial elbow pain. Symptoms can also include paresthesias, numbness or weakness in the ulnar nerve distribution, or feelings of laxity.50 The milking test places strain on the ulnar collateral ligament and will be painful.51 Testing for laxity as compared to the contralateral side can identify a tear (Fig. 28–5).
Plain films can highlight ossification centers in youth athletes, and it is recommended to obtain contralateral films if any question of widening of space appears. MRI arthrogram is necessary to specifically identify a tear, as regular MRI is often inconclusive.51 Dynamic ultrasound for laxity has also been found to be useful in the diagnosis of UCL pathology.52
Management includes therapy specifically targeting core and scapular weakness, as it may lead to increased strain on the medial elbow in order to generate greater force, and so remembering the importance of the kinetic chain and addressing its imbalances is an important piece of a successful treatment regimen.53 If the ligament is torn, then surgical consideration should be discussed if the athlete has not been able to return to their prior level of play.
Athletes should have normal range of motion and strength prior to being cleared to return to sport. Conservative treatment with rest and therapy should allow for successful return to play in 4 to 6 weeks. Athletes undergoing surgical reconstruction should expect to return to play with overhead throwing in 9 to 12 months.54 Surgical outcomes are good, with over 90% of athletes able to return to the same or higher level of play.55
Athletes report pain in a specific area of the elbow. It is important to determine whether the overuse resulted from sport (golf is typical for lateral and tennis for medial) or nonsport motions (i.e., work-related repetitive injuries). Pain is often elicited with resisted wrist flexion for medial epicondylitis and wrist extension for lateral epicondylitis (Cozen’s test)56 (Fig. 28–6).
Figure 28–6
Cozen test: physician testing dorsiflexion of a patient’s wrist against resistance. Resulting lateral humeral epicondylar pain suggests tennis elbow. (Reproduced with permission from Rempel DM, Amirtharajah M, Descatha A. Shoulder, Elbow, & Hand Injuries. In: LaDou J, Harrison RJ, eds. CURRENT Diagnosis & Treatment: Occupational & Environmental Medicine, 5e New York, NY: McGraw-Hill; 2013.)
Diagnostic imaging is not initially indicated. For patients who have failed conservative treatment, x-ray and MRI to rule out other causes of pain is indicated. Diagnostic ultrasound may also be useful to examine for calcifications.57
Management involves change in the amount or intensity of activities that use these motions, addressing any flexibility issues contributing to the poor ergonomics, ice, and consideration of anti-inflammatories. A tension band can be placed to decrease the pull on the muscle origins (tennis elbow band). Wrist immobilization allows for rest of the wrist flexor and extensor muscles. Formal physical therapy may be necessary if symptoms are severe; however, a recent randomized controlled trial recently found therapy to be no better than rest alone. The same trial found that patients who received corticosteroid injection with therapy were worse off at one year compared to placebo injection plus therapy.58 The long-term efficacy of platelet-rich plasma injections is limited. A more recent study found that therapy along with therapeutic ultrasound improved pain and function at 12 weeks compared to corticosteroid injection.59
Athletes should have normal range of motion and strength prior to being cleared to return to sport. Most cases resolve in 12 to 18 months with rest alone.60
The most common cause of carpal tunnel syndrome is poor ergonomics during repetitive-motion tasks (e.g., clerical typing).61 The most common symptom is paresthesia in the thumb, index, and middle fingers, which is the median nerve distribution. Additional symptoms can include a decrease in grip strength or atrophy.
Tests known to help with diagnosis include Phalen’s and Tinel’s test; however, they have mixed reports for their sensitivity and specificity. Nerve conduction/electromyography studies are often performed to assess median nerve function and prior to surgical consideration.62
Treatment involves reassessment of work ergonomics, wearing of nocturnal wrist extension splints, and hand therapy for more serious symptoms.63 Local corticosteroid injection is often a beneficial option for patients without signs of weakness.64 Surgical release should be considered with continued pain, or if weakness is a major symptom, or if muscle atrophy progresses.65
Patients may return to work or play after symptoms have resolved. Patients undergoing surgical release may be out of work for 3 to 6 weeks depending on the type of procedure (endoscopic vs. open).66 Surgical outcomes have shown that patients are generally satisfied with the surgery, and 75% remain asymptomatic at 10 years.67
Scaphoid fracture must be considered with any history of a fall on an outstretched hand. The scaphoid has poor blood supply to its central area and has the potential to lead to avascular necrosis and potentially a malunion. Pain with palpation of the scaphoid area is typical; however, tenderness with volar palpation is also common. It can be difficult to ascertain from pain in the ulnar collateral ligament of the thumb, which can be sprained during the same mechanism of injury. Suspicion should always be high for a scaphoid injury since inappropriate treatment can lead to long-term consequences.68
Plain film views should involve AP/lateral/oblique of wrist in addition to a scaphoid view. Initial x-rays may be negative for fracture and can be repeated in 10 to 14 days; however, occult fractures are still frequently missed. MRI is definitive for diagnosis, although the sensitivity is limited within the first day of trauma69 (Fig. 28–7).
Figure 28–7
Scaphoid fracture in the middle third or waist (arrow). (Reproduced with permission from Escarza R, Loeffel MF, III, Uehara DT. Wrist Injuries. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016.)
One should have a low threshold to immobilize with a thumb spica splint or cast. Surgical pinning may be necessary if evidence of displacement or nonunion becomes apparent.70
Athletes need to be pain-free on palpation with normal range of motion in their wrist and thumb prior to being cleared for return to play. Immobilization for a true fracture should be 4 to 6 weeks, but the time to return may be shorter in cases of suspected fracture in which symptoms resolve. Return to play following surgical pinning should be expected at 3 to 5 months.71
A boxer’s fracture is a fracture of the fifth metacarpal. Its name identifies the most common cause of this injury: punching an object or a person. Males experience this fracture at higher rates than females.72 Overt swelling and bruising on exam are common. Important considerations on exam for this fracture and any metacarpal fracture include shortening of digits, angulation, or rotation. This can best be accomplished by comparing to the contralateral hand. Appropriate rotational alignment is demonstrated by placing the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints in flexion. The phalanxes of each finger should be pointing toward the scaphoid.73
Posteroanterior (PA), lateral, and oblique x-ray views should be obtained. The maximum allowance of degree of angulation and rotation of digits is mainly based on expert opinion.74 There is more allowed tolerance in the fifth digit and progressively less tolerance with each subsequent metacarpal75 (Fig. 28–8).
Treatment for metacarpal fracture is splinting through either radial or ulnar gutter splints or using a clamshell. The position of safe immobilization (POSI), also known as the intrinsic-plus position, is 0 to 30 degrees of wrist extension, 70 to 90 degrees of metacarpophalangeal joint flexion, and full extension of the interphalangeal joints.76 While conservative management with fracture reduction with subsequent casting or splinting has found to have overall satisfactory results in small studies, there should be high suspicion for instability for this type of fracture, and those may necessitate surgical pinning.77 As the fifth digit is less imperative for fine motor skills and grip strength, there is greater allowance of abnormality. Fractures involving the articular surface and comminuted fractures should be referred for surgical consultation.
Athletes can be cleared once there is evidence of healing of the fracture radiographically and they are pain-free on palpation with painless range of motion.
In a large retrospective study of emergency room visits, hand fractures accounted for 19% of all fractures.78 Phalangeal fractures accounted for 59% of the hand fractures, and 33% were metacarpal fractures. Thirty-eight percent of the fractures were in the fifth metacarpal or digit. Common causes include trauma to an outstretched hand from a fall or trauma to a digit into forced flexion or extension. This injury is more common in young males. Mallet (disruption of the extensor tendon to the distal phalanx) and boutonniere (disruption of the central extensor tendon on the middle phalanx) deformities can arise if tendon involvement occurs.
Diagnosis is via plain films. Musculoskeletal ultrasound can also be used to assess in real time.
Treatment for phalangeal fracture is immobilization with splinting while having careful consideration for duration, as range of motion can be lost if immobilization persists too long. Buddy taping to the adjacent digit is a nice alternative therapy, as it allows for some movement while still providing support. If the fractures are unstable, involve the phalangeal neck, or are comminuted then referral to a hand surgeon is warranted.79
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
