Injury Types, Assessment, and Management
Matthew Gotlin, MD, and Laith Jazrawi, MD
Despite excellent conditioning, proper form and technique, state-of-the-art equipment, and numerous preventive strategies, athletes get injured. Injuries come in different shapes and sizes. Being able to identify an injured athlete is paramount for timely intervention. In most cases a serious injury is obvious but at times can be overlooked, especially while one is tending to other injuries. This chapter provides a broad overview of the different types of athletic injuries one may encounter, along with initial assessment and management strategies. We will categorize injuries based on the tissue or system injured, discuss principles of treatment approaches, and provide a comprehensive pathway to allow the athlete a safe return to sport.
Injuries by Structure or System
Depending on the part of the body and the mechanism of injury, different components of the musculoskeletal unit may be damaged. Of all sports injuries, those to muscles, tendons, and ligaments are the most common. Naturally, the more physical a sport is and the more contact and high-energy collisions it involves, the greater the risk for injuries. American football and rugby are more likely to cause fractures, for instance, than tennis or basketball, in which ankle sprains and overuse injuries tend to be more common.
The three most common injuries to bones are acute fractures, stress fractures, and bone contusions. A fractured bone and a broken bone are the same thing; one is not worse than the other. Of the 206 bones in the human body, some are more at risk than others to be injured during athletic events. Immediate pain, inability to bear weight, loss of motion in the limb, and swelling should raise your suspicion for bony injury. If a bony injury is suspected, the limb should be immobilized, and X-rays should be obtained at an emergency room or a physician’s office as soon as possible. The three types of bone injuries are discussed next in more detail.
Sudden bending, twisting, or compression of a bone that causes an immediate break is called an acute fracture. Acute fractures are more common in high-collision sports, although they can occur in noncontact sports as well. They are usually the result of direct trauma to an extremity, but can also be caused by sudden bending or twisting. An athlete with an acute fracture usually has significant localized pain in the area, immediate swelling, and possibly deformity (which means the limb may be bent in an abnormal way). Key findings that may lead you to suspect an acute fracture include an inability of the athlete to bear weight across the bone, obvious deformity of the limb, or an audible “snap” or “crack” at the time of injury. Different types of acute fractures are discussed next.
Simple or Nondisplaced Fractures Simple or nondisplaced fractures (see figure 3.1) are those in which a break is noted on an X-ray, but the bone is still in perfect position or alignment. These fractures are often referred to as “hairline fractures.”
FIGURE 3.1 Simple fracture.
Displaced Fractures Displaced fractures involve either a separation or an angulation of the fracture segments (see figure 3.2). Displaced fractures frequently require reduction (manipulating the bone to restore alignment) and may require surgery.
FIGURE 3.2 Displaced fracture.
Comminuted or Impacted Fractures Comminuted or impacted fractures are those in which one part of the broken bone is pushing into the other, shortening the length of the bone and resulting in many small bone fragments (see figure 3.3). This type of fracture is serious because loss of bone length can adversely affect the function of the bone. Such breaks are seen in fractures of the wrist when athletes instinctively try to break a fall with their outstretched hands.
FIGURE 3.3 Impacted fracture.
Compound or Open Fractures Compound or open fractures are those in which the bone pierces through the skin (see figure 3.4). These fractures are usually related to severe trauma (e.g., motorcycle crashes) but can occur in any high-impact sport. Rodeo cowboys and football and rugby players are particularly susceptible to compound fractures. Some compound fractures are very obvious because a piece of bone is sticking out of the skin; however, others may be more subtle. If there is any skin compromise (laceration, abrasion, bleeding) around a potential fracture, you must have high suspicion for a compound fracture. These are surgical emergencies!
FIGURE 3.4 Compound fracture.
Fracture Dislocations Fracture dislocations are injuries that involve a break in a bone as well as damage to ligaments and muscles, causing the broken bone to dislocate at the joint (see figure 3.5). These types of injuries are usually caused by high-energy mechanisms such as motor vehicle accidents. Gross angulation or deformity at any joint should raise suspicion for a fracture dislocation.
FIGURE 3.5 Fracture dislocation.
Physeal Fractures Physeal fractures are those that occur through the growth plate in children. The physes, or growth plates, are located near the ends of the long bones and are vulnerable to injury. When fractures penetrate the growth plate (see figure 3.6), they can adversely affect future growth of the long bones. Such breaks must be handled with extreme care.
FIGURE 3.6 Physeal fracture.
Physeal fractures are classified using the Salter-Harris Classification system (Salter 1992). There are types I through V depending on the location and pattern of the fracture. The Salter classification relates to how involved the growth plates are in the injury. Salter-Harris type II fractures are the most common. When the fracture is extensive through the growth plate, the healing process can dangerously affect the future growth of the bone. Physeal fractures often occur in the wrist and ankle of children.
Avulsion Fractures Avulsion fractures occur when a tendon or ligament pulls a piece of bone off (see figure 3.7). The injury to the soft tissue structure is often the primary focus of treatment, unless the piece of bone pulled off is very large. Avulsion fractures are frequently seen in injuries to fingers. Baseball catchers are notorious for avulsions in the fingers.
FIGURE 3.7 Avulsion fracture.
A stress fracture is an overuse injury in which normal bone is subjected to repetitive stress, resulting in microfractures (see figure 3.8). In general, female athletes and military recruits are at increased risk for stress fractures (Joy and Campbell 2005). They most commonly occur in the tibia (shin bone), femoral neck (female athletes), or metatarsals (foot bones in ballet dancers) (O’Malley et al. 1996). Athletes may have insidious onset of symptoms rather than an acute injury. Often, the diagnosis is not made until after healing has taken place and new bone has been laid down. Often no treatment other than rest is necessary. If a weight-bearing bone, like the femur or tibia, is affected, weight should not be placed on the bone while it is healing; for a leg bone injury, the athlete must use crutches for a period of time. The amount of rest required depends on the type and degree of stress fracture. In some cases of stress fracture, X-rays might not show a break, so a nuclear bone scan, magnetic resonance imaging (MRI), or computed tomography (CT) scan is needed for diagnosis.
FIGURE 3.8 Stress fracture.
Bone contusions or bone bruises are very common injuries in contact sports. They occur from direct trauma to a bone but do not result in fracture. Instead there is a local inflammatory response in the periosteum (layer of tissue surrounding the bone), and a hematoma (bruise) usually forms in the surrounding soft tissue. It can result in pain, loss of motion of the limb, and enormous bruising. It can occur in any bone, but iliac crest contusions (hip pointers) and shin bone contusions are very common in hockey and football players (Anderson, Strickland, and Warren 2001). A fracture must always be ruled out with an X-ray before diagnosing an athlete with a bone contusion.
Red Flags for Suspicion of Fracture
Recognition and identification of suspect fractures is of utmost importance. Missed fractures can lead to significant morbidity. Ruling out a fracture should be one of the first things done when evaluating an athlete with a significant injury. The mechanism of injury should be your first clue to a possible fracture. High-energy collisions and excessive bending or twisting can lead to fractures. There are also signs and symptoms that should raise your suspicion for a fracture, as follows:
- Pain with weight bearing
- Wound around injury site with active bleeding
FIGURE 3.9 Bone covered by articular cartilage.
Ligament and Joint Injuries
The area where two bones come together is called a joint. The bones in this area have a cap covering the ends called articular cartilage (see figure 3.9). This cartilage acts to decrease friction and distribute loads about the joint. Joints are held together by tough but not very flexible tissues called ligaments. Ligaments are mainly composed of type I collagen. Many joints involve motion, such as the elbow, which is a hinge joint, or the shoulders and hips, which are ball-and-socket joints. Ligaments can surround a joint, acting as a capsule, such as the ligaments surrounding the hip and shoulder. Ligaments can also be free-standing structures that independently provide support to a joint, such as the ligaments surrounding the knee. Ligaments function to restrict joint motion, stabilize a joint, and help with joint proprioception. Injuries that occur to joints can result in damage to the ligaments or articular cartilage, and in many cases chronic ligament injuries can lead to cartilage damage.
Injuries to ligaments are called sprains. Sprains usually occur from twisting or bending injuries around a joint. When a joint twists or bends beyond its normal capacity, the ligaments can tear (see figure 3.10). In adults, this usually results in a midsubstance tear of the ligament, whereas in children the ligament usually tears at the bone insertion (sometimes causing an avulsion fracture). Sprains are classified into three grades. Grade I are mild sprains, grade II are moderate sprains or partial tears of the ligament, and grade III are complete tears of the ligament (see figure 3.11).
FIGURE 3.10 Knee collateral ligament tear.
Pain around a joint may indicate a sprain, especially if the mechanism of injury was a twist or a bend about that joint. The athlete may have heard a “pop” and felt the joint “give out” or “give way.” This usually leads to immediate swelling around the joint, and may feel as if the joint is unstable. In mild or moderate sprains, range of motion may not be painful or compromised and weight bearing could be tolerable. Therefore, these injuries can often be missed.
FIGURE 3.11 Grades of sprains.
Ligament sprains and tears can occur anywhere in the body. The ankle and knee are very common areas of ligament injuries due to the pivoting and twisting motions endured in these joints during sports. Good mechanics and appropriate stretching and conditions, as well as appropriate equipment, can be used to limit ligament injuries.
Other joint injuries include subluxations, dislocations, osteochondritis dissecans, chondromalacia, and osteoarthritis. They are briefly touched upon here but discussed in more detail in later chapters.
Subluxations are partial or incomplete dislocations in which a joint may briefly move out of place (see figure 3.12). They can cause damage to surrounding ligaments and articular cartilage. Dislocations are an injury where complete loss of bony contact occurs in a joint (see figure 3.13). Dislocation almost always causes ligament damage and leads to instability of the affected joint. If there is gross deformity of a joint, you must be concerned about fracture or dislocation or both. The kneecap (patella) and fingers are common sites of subluxations and dislocations.
FIGURE 3.12 Subluxation of shoulder joint.
FIGURE 3.13 Dislocation of finger.
Osteochondritis dissecans is a condition in which the articular cartilage in a joint is damaged spontaneously (see figure 3.14). This can occur in adults but most often occurs in adolescents between 10 and 15 years of age. It can be hereditary or traumatic. Seventy percent of osteochondral lesions occur in the knee (Kocher et al. 2006). Patients typically complain of vague, poorly localized pain. Activity modification and surgery are often indicated for advanced cases. Chondromalacia is another defect described as softening of the articular cartilage and may cause joint symptoms (diffuse discomfort with activity) in adolescent and young athletes. The articular cartilage behind the kneecap (patella) is typically affected (Hong and Kraft 2014). This is a disabling condition for the active person and can be successfully treated with physical therapy.
FIGURE 3.14 Osteochondral lesion.
Osteoarthritis is the degeneration of articular cartilage. The caps of cartilage that help the joint move smoothly and painlessly are worn out. The exact cause of osteoarthritis is unknown, but chronic “wear and tear” and mechanical loading of a joint play a role. There has been research describing a possible genetic component of osteoarthritis. (Zengini 2018). It is usually a problem for older athletes and is most common in the hips, knee, and thumb. With the higher level of athletic participation in the aging population, managing osteoarthritis has become of greater interest and need. Interventions with medications, injections, and surgery play an increasing role for this population.
Tendon and Muscle Injuries
Tendons are the parts of muscles that attach to bones. Tendons transfer the force from muscle to bone to produce joint motion. The muscle–tendon unit (also called the musculotendinous unit) can help stabilize joints. A good example is the shoulder’s rotator cuff, which forms a partially circumferential covering around the joint that provides not only dynamic control of motion, but also stability. More significantly, the muscle–tendon unit is responsible for body movement and strength. The length and size of a body’s muscle–tendon units depend largely on degree of training, heredity factors, and general health of the individual. Specific training can affect the size and function of the muscle–tendon unit. Injuries can occur anywhere along the muscle–tendon unit (e.g., tendon insertion, midsubstance of the tendon, musculotendinous junction, the muscle belly proper, or the muscle origin).
Whereas injuries to ligaments are called sprains, injuries to tendons and the rest of the muscles are called strains. Strains are very common sports injuries and usually occur during eccentric loading of the tendon, that is, contraction of a muscle as it lengthens. Older athletes are at higher risk for strains because the elasticity of the tendon decreases as one gets older. Strains to the muscles can be minor or can involve significant compromise to the tendon’s integrity. Strains (also called pulled muscles) generally occur at the musculotendinous junction. Common sites of muscle strains are hamstring, quadriceps, and gastrocnemius (calf). Strains usually cause a sudden onset of pain, swelling, and bruising, as well as pain when one attempts to use the injured muscle.
Strains are graded on a scale of I to III based on the severity of injury to the muscle–tendon unit (see figure 3.15). In a grade I strain, a stretching and microtearing of the muscle fibers occurs, with minimal disability or loss of strength. Grade II strains result in partial tearing of the muscle–tendon unit, causing definitive functional deficits and a loss of strength. Grade III strains involve complete tearing of the muscle–tendon unit and result in severe functional deficits and significant weakness.
FIGURE 3.15 Muscle strains.
Muscle contusions (bruises) are extremely common injuries in all sports. They typically occur after direct trauma to a muscle. Whether it is a lacrosse ball coming into contact with a player’s thigh, an opponent’s knee hitting a player’s arm during a tackle, or a fall onto one’s buttock during a race, muscle contusions occur frequently and have different severities. High-energy contusions can lead to significant swelling, bruising, and loss of function.
Inflammation of tendons or the sheath surrounding such tendons due to repetitive motion or injury is called tendinitis. Tendinitis can be caused by a severe injury or can be a chronic condition. The chronic injuries—which are caused by overuse or poor body mechanics—are the most difficult to treat. A well-known sports injury, lateral epicondylitis (better known as tennis elbow; see p. 129), is a prime example of chronic tendinitis. As a result of overuse, playing too much tennis, or hitting using bad technique, many tennis players develop chronic tendinitis on the outside of their elbow. More commonly, everyday activities that require repetitive wrist extension such as typing on a computer or painting can lead to this problem. Chronic problems of the tendons are very difficult to treat.
Skin Injuries and Problems
Some serious sports-related problems can affect the skin. For example, skin infections (see figure 3.16)—fungal, viral, and bacterial—are common in athletics and are often present in athletic training rooms. Athlete’s foot is a common fungal infection that can result from walking barefoot on dirty locker room floors or not changing socks frequently enough. It is best treated by maintaining good hygiene, keeping the feet dry, and applying appropriate powders or ointments for flares. If the nails appear eroded and are breaking, a fungal infection may be present. This condition is more difficult to treat and may require systemic medications and removal of the affected nail(s). If symptoms of a fungal nail infection arise, professional medical care is warranted.
FIGURE 3.16 Skin infection.
Staph infections (staph aureus) and Methicillin resistant staph aureus (MRSA) are serious bacterial skin infections that periodically appear in and around athletic training rooms. These infections usually present with warmth, redness, swelling, and pain in the affected area. Having cuts, abrasions, or other forms of skin breakdown increases one’s risk for these infections. Methicillin resistant staph aureus is very difficult to treat, so proper sanitizing regimens are absolutely necessary to prevent this and other skin infections. Equipment must be wiped down with proper antiseptic solutions, sharing of dirty towels must be prohibited, and personal hygiene must be stressed.
Blisters—a common injury typically caused by overuse, poorly fitting equipment, or improper mechanics—can undermine any athlete (see figure 3.17). Blisters might not look like much of a problem, but they can get infected or can get larger and become a significant nuisance.
The same is true of chafing injuries and abrasions. Skin irritations must be kept clean and receive proper treatment. Chafing is fairly common in long-distance runners who wear shoes that do not fit properly. Chafing is also common among bicyclists who wear ill-fitting biker shorts or have poorly adjusted bicycle seats. Scrapes or abrasions (see figure 3.18) are particularly common among skateboarders and are also seen frequently in athletes who play on grass fields such as those in soccer, American football, or baseball.
FIGURE 3.17 Blister.
FIGURE 3.18 Abrasion.
Lacerations are cuts or gashes to the skin that are usually linear (see figure 3.19). Lacerations come in different depths, and the deeper they are, the more at risk they are for infection and damage to underlying structures (nerves, arteries, and veins). Deep lacerations should be immediately evaluated by a physician in order to assess underlying damage and will likely need suture repair.
FIGURE 3.19 Laceration.
Many outdoor sports, including tennis, swimming, basketball, outdoor volleyball, and running, expose athletes to excess sunshine. Skin cancer has become more prevalent, especially in the Sunbelt states. Outdoor athletes must wear sunblock, shaded hats, and proper clothing for protection. Sunblock should protect against both ultraviolet (UV)A rays (which age the skin) and UVB rays (which burn the skin) and must be reapplied frequently (at least every two hours). When outdoors, athletes should seek shady areas when possible and drink plenty of fluids to prevent heat-related illnesses.
Ear, Eye, and Mouth Injuries
Injuries to structures of the face can occur in any sport. With the advancements in sports equipment, these injuries are becoming less common. Cauliflower ear (auricular hematoma) is common in wrestlers and is due to repetitive ear trauma against the wrestling mat or an opponent (see figure 3.20). It can be treated with aspiration and wrapping but can be prevented altogether by using proper headgear.
Eye injuries are common in baseball, basketball, racquetball, and martial arts. Athletes may experience vision loss, blurry vision, double vision, or floaters or flashers. Some nonurgent eye conditions are corneal abrasions (see figure 3.21) and traumatic mydriasis (contusion of the iris sphincter causing a dilated pupil). Other emergent eye conditions include hyphema (blood in the anterior chamber of the eye), orbital wall fractures (see figure 3.22), and ruptured globe.
The most common dental injury athletes may encounter is an avulsed tooth—getting a tooth “knocked out.” The likelihood of the tooth surviving and being able to be replanted depends on the amount of time the tooth is out of the socket; therefore, this is a dental emergency. The tooth should be rinsed with saline and transported in milk, saliva, or sterile saline (Kranser 2000).
FIGURE 3.20 Cauliflower ear.
FIGURE 3.21 Corneal abrasion.
FIGURE 3.22 Orbital fracture.
Other Systemic Injuries
Two injuries that can have catastrophic effects on systems throughout the body are heat injuries and sudden cardiac death. Various types of heat injuries occur and are differentiated by severity. They include heat cramps, heat syncope, heat exhaustion, and heatstroke.
Heat cramps (actually a form of dehydration) are probably the most painful and yet the least serious of heat-related injuries. A lack of fluids and essential minerals causes muscles, especially leg muscles, to cramp. Cramps can also occur when athletes drink too much water and do not adequately replenish electrolytes. Athletes should cool down, stretch, and drink electrolyte solutions. Caution must be taken not to overhydrate with only water (i.e., electrolytes must also be replaced) because a condition known as hyponatremia can result. This is a medical emergency and a condition that can be catastrophic.
Heat syncope is a short loss of consciousness due to blood vessel dilation in the setting of high temperatures (Khosla and Guntupalli 1999). Athletes will have normal body temperature and should be treated with fluid replacement and lying down with leg elevation.
Heat exhaustion is a more serious condition and is caused by a higher degree of dehydration. It is the most common heat-induced condition. Athletes with heat exhaustion will have elevated body temperatures, but core body temperature is less than 102.2 degrees F (39 degrees C) (Khosla and Guntupalli 1999). They will present with profuse sweating and may have nausea and vomiting.
The most serious kind of heat injury is heatstroke, in which the thermostat in the brain ceases to work. This is a true medical emergency and must be treated in a hospital. Athletes will present with hot and dry skin (normal sweating mechanism does not work), fast heart rate, and body temperature over 106 degrees F (41 degrees C) (Khosla and Guntupalli 1999). Treatment revolves around reducing core body temperature (ice immersion, cooling blankets, fanning, intravenous hydration).
Sudden cardiac death is a rare yet unfortunate risk of athletic participation. The overall prevalence is about 0.3 percent (O’Connor and Knoblauch 2010). In young patients, the most common cause of sudden death stems from a condition called hypertrophic cardiomyopathy (HCM), which is an enlargement of the heart (Borjesson and Pelliccia 2009). Hypertropic cardiomyopathy is a congenital condition in which atypical muscle can be identified by electrocardiogram and echocardiogram. Other conditions much as coronary artery disease (clogged arteries in older athletes), commotio cordis (blunt chest trauma in children and adolescence), and long QT syndrome (hereditary or acquired condition) can cause sudden cardiac death.
Syncope or “passing out” episodes in a young athlete is a red flag for a serious cardiac illness and warrants medical evaluation. At this time it is not economically feasible to test everyone who wants to participate in sports, but routine preparticipation screening in the United States can help us identify athletes who are at higher risk for cardiac events (Bader, Goldberg, and Sahn 2004). According to the American Heart Association,
a complete and careful personal and family history and physical examination designed to identify (or raise suspicion of) those cardiovascular lesions known to cause sudden death or disease progression in young athletes is the best available and most practical approach to screening populations of competitive sports participants, regardless of age (Lyznicki, Nielsen, and Schneider 2000, 766).
When assessing an injury, use your eyes and ears. Common sense will take you a long way. Obviously, a certain amount of knowledge is necessary, but many conditions or symptoms will be apparent. For instance, one can recognize a dislocated shoulder by the athlete’s obvious discomfort and deformity of the shoulder. A displaced or compound fracture of the tibia and fibula can be easily differentiated from a benign contusion. Rapid swelling of an injured part is more ominous than no swelling. Inability to bear weight on an extremity is also a worrying sign. A pale sweaty athlete has heat exhaustion, whereas a ruddy complexion might indicate heatstroke. An athlete who has injured a knee and mentions hearing a pop may have a torn anterior cruciate ligament. Someone with a concussion might be fine right after the blow and five minutes later not know what day it is.
Basic Principles of Injury Assessment
Basic principles of obtaining a thorough history and performing a physical examination will allow you to hone in on an accurate diagnosis. For acute injuries, excluding a head injury, the following five simple questions should be asked:
- Where is your pain?
- How did the injury happen? (mechanism of injury, position of limb during injury)
- Did you hear a pop, crack, or snap?
- Does it hurt when you move the body part—does it feel unstable?
- Can you bear weight on the leg? (if a lower body injury)
For chronic injuries, the assessment becomes more complex. Pertinent information includes duration of symptoms, alleviating and aggravating factors, nature or description of the pain, prior treatments, functional deficits, numbness or tingling, weakness, swelling, instability or “giving way,” or mechanical symptoms such as locking or catching.
Certain “red flag” signs should prompt emergency medical evaluation. These signs include disorientation following a head injury (see chapter 4 for more information on head injuries), inability to walk or move extremities following a collision or fall, inability to bear weight, numbness or tingling following back or extremity injury, and an obviously dislocated body part (e.g., shoulder, toe).
Diagnostic Tools for Injury Assessment
Among the most helpful instruments for assessment and diagnosis, particularly for fractures and other injuries to the skeletal system, are X-rays. X-rays cannot adequately detect soft tissue structures, such as ligaments or cartilage, but they can evaluate bones with the exception of subtle fractures such as fresh stress fractures, which might not be easily visualized on an X-ray. X-rays do involve a minimal amount of radiation exposure, so they should be used only when necessary. They are relatively inexpensive compared to other imaging methods and are widely available.
Examination of the Injured Athlete
If you are a coach or athletic trainer, when examining an athlete, you must fully expose the injured body part. That includes removing clothing over the injured area and any equipment that may interfere with a complete and thorough evaluation. Inspect and palpate the injured area, assess strength and range of motion, and perform a basic neurovascular exam. Inspect the area for swelling, deformity, bruising, abrasions or lacerations, and asymmetry. Especially for extremity injuries (arms and legs), always compare to the uninjured side to catch subtle differences in appearance. Ask the athlete to point to the area of most pain and begin to press gently around that area to identify exactly what is injured. If suspicion for fracture is low, one should ask the athlete to move the injured body part and assess for pain tolerance.
For every injured extremity, it is imperative to perform a very basic neurovascular exam. This includes asking the patient to move the extremity, checking hands or feet (or both) for sensation differences, and making sure the athlete’s hands or feet (or both) are warm and blood is flowing through the area (for practitioners with training to check pulses, this is more accurate). If there is any suspicion for nerve or vessel (artery or vein) injury, the athlete must seek immediate medical attention. Red flags include inability to move the extremity (this may be limited by pain, so the athlete should be asked to perform simpler tasks like wiggling toes), numbness or tingling, and a pale or cold extremity.