Fig. 9.1
Heterotopic ossification of the right hip. An irregular linear lucency is seen in the subcapital region. (a) AP view of the right hip. (b) Lateral view of right hip
The differential diagnosis for right hip pain is extensive in both able-bodied and disabled athletes. In the absence of obvious trauma, the differential diagnosis is narrower and includes conditions such as osteoporotic fractures, osteoarthritis, septic arthritis, heterotopic ossification, and hip dislocation. In this case, the most likely diagnosis is heterotopic ossification. Heterotopic ossification (HO) is common in SCI, particularly in athletes. In SCI, the hip is the most common joint affected by HO. Radiography was diagnostic, demonstrating abnormal periarticular bone deposition. Ectopic bone formation is responsible for the limitations in range of motion and pain. In this chapter, we focus our discussion on the most common causes of hip and pelvis dysfunction in the disabled athlete population.
9.2 Introduction
For centuries, able-bodied individuals have engaged in athletic competitions. However, it has only been since the middle of the twentieth century that individuals with physical impairments have been able to participate in competitive sporting events. As a result, functional impairment is no longer a barrier to participation in athletics, and interest in accommodating the needs of those with disabilities continues to grow.
The psychological and physical benefits of exercise are numerous and include improved self-concept, psychosocial attitude, social awareness, social reintegration, perception of well-being, and health [1, 2]. Studies show that exercise can significantly increase psychological well-being in wheelchair athletes [1]. Disabled individuals who participate in athletic activities demonstrate better cardiopulmonary endurance, exercise tolerance, mobility, balance, cardiovascular health, and less obesity when compared to those who do not participate [3]. Engaging in sports may also improve bone mineral density (especially for those who are at a wheelchair mobility level) [4]. Proprioceptive related activities have been associated with improved amputee weight-bearing and gait [5].
It is well known that physical fitness levels are decreased for individuals with disabilities compared to their able-bodied counterparts [2]. Involvement in sports can significantly improve quality of life and life expectancy, which consequently decreases hospital admissions and medical complications [6]. Individuals who are disabled but active have fewer cardiac risk factors including a better lipid profile [7, 8].
Studies have shown that the injury rate and type of injuries are similar for both disabled and able-bodied athletes [9]. According to injury data [10], the most common injuries in parathletes (1976 forward) are sprains, strains, abrasions, contusions, fractures, and dislocations. Location of injury is sport- and disability-related (Fig. 9.2). Lower extremity injuries occur more frequently in ambulatory athletes (visually impaired, amputee, cerebral palsy), while upper extremity injuries are more common in wheelchair athletes. Most injuries required less than 7 days without participation in the sport. [10]
Fig. 9.2
Predominant unique body region of soft tissue injury for the United States Association of Blind Athletes (USABA), Wheelchair Sports USA (WUSA) athletes, and Disabled Sports USA (DSUSA) athletes. Reprinted from Nyland J, Snouse SL, Anderson M, et al. Soft tissue injuries to USA paralympians at the 1996 summer games. Arch Phys Med Rehabil 2000;81:368–73. With permission from Elsevier
9.3 History of Disabled Athletics
Sir Ludwig Guttmann, a German-born refugee from Nazi occupation, is credited with originating and popularizing organized sports for the disabled. As a British neurosurgeon and director of the National Spinal Injuries Center at Stokes-Mandeville Hospital in London, Guttmann established a comprehensive rehabilitation program for paralyzed patients and incorporated athletics. On July 28th 1948, Guttmann organized a sports competition for World War II veterans with SCI on the same day as opening ceremonies as the London 1948 Olympic Games [11]. All the participants were wheelchair athletes. What began as recreational rehabilitation is considered to be the origin of athletic competition for individuals with disability. Four years later, Guttmann’s event was transformed into an international competition when a Dutch Ex-serviceman joined the games. The Paralympics were born [12].
The Paralympics, which began, in Rome, as an event consisted of 600 athletes from 23 different countries.. In 2012 at the London Paralympics, there were 4237 participants from 164 countries and at the Sochi 2014 Winter Paralympics, there were 545 participants from 54 countries [13, 14]. As the number of athletes grows, the training, competition, and criteria for participation have become more rigorous [13]. And as such, it should be expected that injury rates will increase as well. In a study by Derman et al. [15], a total of 475 injuries were reported in 387 athletes at the London 2012 Paralympic Games. Seventy percent of all injuries were acute, with upper limb being the most injured. However, it is still essential to note that there were 9 injuries in the pelvis/buttock, 18 in hip/groin, and 30 in the thigh [15]. As the number of disabled individuals participating in sports continues to rise, it is important that physicians are able to meet the needs of this population.
9.4 Classification System
Athletes are categorized using the International Paralympic Committee’s Classification system (Table 9.1). The system classification provides a structure for competition. This system was developed to decrease the impact of impairments on sport performance by determining who is eligible to compete in a certain para-sport and by grouping the eligible athletes in sport classes according to their activity limitation in that particular sport [16]. Each Paralympic sport has its own classification system and is developed by the International Federation (IF) governing that sport. It can be used to re-evaluate an athlete throughout their career as some disease processes changes over time. IF decides how severe an impairment must be in order for athlete to be eligible to compete in that sport. The only exception is the classification for athletes with visual impairments which remains a medical system [16].
Impairment | Explanation |
|---|---|
Impaired muscle power | Reduced force generated by muscles or muscle groups, may occur in one limb or the lower half of the body, as caused, for example, by spinal cord injuries, spina bifida or poliomyelitis |
Impaired passive range of movement | Range of movement in one or more joints is reduced permanently |
Limb deficiency joints that can move beyond the average range of motion, joint instability, and acute conditions, such as arthritis, are not considered eligible impairments | |
Limb deficiency | Total or partial absence of bones or joints, from birth or as a consequence of trauma (e.g., car accident or amputation) or illness (e.g., bone cancer) |
Leg length difference | Bone shortening in one leg from birth or trauma |
Short stature | Reduced standing height due to abnormal dimensions of bones of upper and lower limbs or trunk, for example due to achondroplasia or growth hormone dysfunction |
Hypertonia | Abnormal increase in muscle tension and a reduced ability of a muscle to stretch, which can result from injury, illness, or a health condition such as cerebral palsy |
Ataxia | Lack of coordination of muscle movements due to a neurological condition, such as cerebral palsy, brain injury or multiple sclerosis |
Athetosis | Generally characterized by unbalanced, uncontrolled movements and a difficulty in maintaining a symmetrical posture, due to cerebral palsy, brain injury, multiple sclerosis, or other conditions |
Visual impairment | Vision is impacted by either an impairment of the eye structure, optical nerve/pathways or the part of the brain controlling vision (visual cortex) |
Intellectual impairment | A limitation in intellectual functioning and adaptive behavior as expressed in conceptual, social, and practical adaptive skills, which originates before the age of 18 |
Functional classification of an athlete’s impairment depends on how much that impairment impacts sports performance. For example, athletes with spinal cord injury resulting in lower extremity paresis can now compete with double above-knee amputees in wheelchair races. Their functional classification considers both impairments to be similar and will have limited problems with propelling a wheelchair, despite having different etiologies [16].
All assistive devices, prosthetics, or other adaptive equipment must be examined to ensure fair competition. For example, an above-knee-amputee skier with either knee disarticulation or hip disarticulation must use a three-track system (ski with two outriggers) [12].
In this chapter, we will discuss the challenges of athletes who use wheelchairs, amputees, and cerebral palsy.
9.5 The Amputee Athlete
The most common musculoskeletal injuries among amputee athletes are sprains and strains to the lumbar spine and sacroiliac joint on the uninvolved side. These injuries are attributed to the mechanical stress of the ground reaction forces during running or ambulation and the asymmetric biomechanical force transmission patterns of the involved and noninvolved sides. In addition, prosthetic alignment (increased hip flexion and ankle plantar flexion) contributes to lumbar spine and pelvic injuries, by causing increased lumbar lordosis [17]. It is important for the sports physician to understand the impact of prostheses and other adaptive equipment on the biomechanics of the specific sport.
9.5.1 Overview
The amputee athlete has a variety of options for adaptive equipment . The new, lightweight, more durable, and better engineered adaptive devices have enabled amputee athletes to attain a better gait pattern [1]. As a result, these athletes can engage in almost any sporting activity. Depending on the type of lower extremity amputation, gait and biomechanics are affected differently. As noted above, it is important that the physician understand (1) the types of amputation, (2) the various adaptive equipment options, (3) biomechanical considerations, and (4) how these factors impact athletic injuries.
Regardless of the level of amputation, there is an automatic change in biomechanics both with and without the use of a prosthesis. The higher the level of amputation, the greater the biomechanical considerations: more energy is required to complete basic functional activities , weight-bearing demands on the residual limb are increased, and the center of gravity is altered, compromising stability and increasing the likelihood of falls. As a result, balance-dependent tasks are more challenging for these individuals [1].
Transfemoral prosthesis has evolved and has locking mechanisms taking up more space distal to the socket [18]. A shorter residual limb has biomechanical and functional consequences. Longer residual limbs enable greater stability for sitting, augment transfers, and provide a more secure suction for the prosthesis which is important for active athletes [18]. In a study by Baum et al., it was found that there is significant correlation between increased pelvic tilt excursion and smaller limb ratios. Unilateral transfemoral amputees who have shorter residual limbs tend to have an anterior tilt of the pelvis prior to toe-off and a remarkable posterior pelvic thrust to swing the prosthetic leg forward. This exaggerated pelvic tilt is secondary to inability to securely attach the hamstrings and quadriceps due to decreased availability of tendon attachment. Those with longer residual limbs such as a knee disarticulation have a more stable and controlled pelvic tilt similar to the uninjured population [19]. Baum postulated that the gait is not profoundly affected if the residual femoral limb length is greater than 57 % of the contralateral intact limb [19]. Thus it is increasingly imperative to understand the type of amputation and prosthetic used in order to anticipate unique biomechanics and gait complications.
Athletes with transtibial amputees also have asymmetric muscle loads around the hip joint specifically, in the adductor and abductor muscle groups which may lead to overuse injuries from running. A study by Kersting et al. [20] revealed that hip and knee joint movements change during running in unilateral transtibial amputees in which there requires a larger power at the hip but reduced power at the knee. Bilateral transtibial amputees were also similarly affected but had a symmetric pattern. Lower-extremity amputee athletes use prosthetics that are adapted for their specific sport. All sports prostheses must be able to withstand the demand placed on them by the athlete. Specific prosthetic components are used for activities such as sprinting, endurance, and jumping. Carbon composite and energy-storing feet, as well as hydraulic, multiaxial, and computerized knee systems improve gait, athletic prowess, and agility. A shock-absorbing mechanism is desirable for endurance activities [12]. Because shock-absorbing devices are heavier, they may reduce speed, and therefore sprinters prefer lighter prosthetic components [12]. Carbon fiber components, particularly feet, have flexible shanks allowing them to deform on loading and recoil at toe-off, increasing energy return [21].
Of note, the residual limb is vulnerable to blistering and swelling at pressure-sensitive areas (fibular head, distal tibia, and femoral condyles for transtibial amputees, and ischium for transfemoral amputees) [1]. In athletes with transfemoral amputations, ischial bursitis can occur as a result of weight-bearing patterns and prosthetic socket design. For the same reason, the greater trochanter and femur can also be affected [1]. An improperly fitting prosthesis can further aggravate the situation [17]. Socket irritation can cause prepatellar, infrapatellar, or pretibial bursitis in athletes with transtibial amputations [22]. Amputee athletes can develop residual limb fractures above the prosthesis [22].
Hyperextension frequently precipitates quadriceps tendon injuries. The quadriceps muscle is subjected to extreme forces during sudden extension movements: acceleration, deceleration, landing, and jumping [12]. The repetitive stress of these forces causes micro-tears at or near the attachment point of the quadriceps tendon to the superior aspect of the patella [12]. Most of the time, these injuries are minimal and do not limit competition. When the symptoms persist or progress, pain will intensify and performance will suffer. Chronic tendinopathy may develop, which could ultimately result in a complete rupture of the quadriceps tendon [12]. Injuries to the uninvolved limb may include plantar fasciitis, Achilles tendonitis, and stress fractures [14–17].
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