Sports Injuries
Riley J. Williams
Thomas L. Wickiewicz
During the past decade, the importance of regular exercise in the maintenance of good health has been well-established. Consequently, with increasing attention now focused on personal fitness, the incidence of sports-related injuries has increased significantly. Both primary care physicians and specialists can expect to see a variety of athletic injuries. All clinicians should be able to recognize these conditions and administer appropriate care. A thorough history, physical examination, musculoskeletal imaging, and laboratory testing are all important in arriving at the proper diagnosis. A treatment plan is then developed for the injured athlete based on these objective findings.
CERVICAL SPINEInjuries to the cervical spine range from mild to severe. Certain athletic activities (football, diving, and gymnastics) are associated with an increased incidence of cervical spinal injury in comparison with other sports. Prompt recognition and treatment of individuals who suffer cervical spinal injuries may prevent the progression or severity of the associated neurologic injury.
II. CLASSIFICATION OF CERVICAL SPINAL INJURIES
Neck injuries can be classified according to neurologic sequelae or the type of force acting on the cervical spine at the time of injury.
Cervical spinal injury with minimal, transient, or no neurologic symptoms
Muscle strains. Pain and neck stiffness with no neurologic findings and negative imaging studies. Usually resolve spontaneously.
Brachial plexus injuries (“stingers” or “burners”). Transient symptoms. See subsequent text.
Bony fracture, ligamentous injury, disc injury without neurologic involvement.
Cervical spinal injuries accompanied by incomplete or complete spinal cord syndromes.
III. CLASSIFICATION BY MECHANISM OF INJURY AND SYNDROME
Flexion without axial load or rotation. These forces usually cause a compression fracture of the cancellous cervical vertebral body without tearing of the stabilizing ligamentous complex of the facet joints. Avulsion fractures of the transverse processes can also occur. These are stable fractures that are usually not associated with neurologic loss.
Flexion with rotation. These forces place high loads on the facet joint capsules and the posterior interspinous ligaments. Unevenly applied forces can cause unilateral facet dislocation resulting from facet capsular rupture. Larger loads can lead to bilateral facet dislocations with associated anterior subluxation of the vertebral bodies and fractures of the facets, laminae, or vertebral bodies. Neurologic trauma
associated with these injuries is quite variable, ranging from no injury to complete spinal cord injury.
Axial compression. This type of load usually results when the head strikes a hard object, as when a swimmer dives into shallow water. With the forward flexion of the head, the cervical lordosis decreases such that the spinal column is essentially straight. The resultant force is transmitted to the cervical spine and can cause vertebral body fracture with retropulsion of bony elements into the spinal canal. Neurologic loss, including quadriplegia or complete motor paralysis secondary to anterior spinal cord syndrome, is commonly associated with this pattern of injury.
Extension. Extension forces that exceed the normal range of motion of the cervical spinal facet joints can lead to fracture of these elements or an avulsion of the superior margin of the vertebral body. Neurologic loss is variable. Occasionally, the spinal cord impingement occurs between the lamina posteriorly and a disc anteriorly. A complete spinal cord injury or a central cord syndrome can result.
IV. SPINAL CORD SYNDROMES
Central. Extension forces; injury affects upper extremities more than lower extremities; motor and sensory loss; fair prognosis; most common type.
Anterior. Flexion–compression; incomplete motor and sensory loss; poor prognosis.
Brown-Séquard’s. Results from penetrating trauma; ipsilateral loss of motor function; contralateral pain and loss of temperature sensation; best prognosis of all spinal cord syndromes.
Complete. Spinal canal disruption and canal compression; no function below site of injury; poor prognosis.
Single root. Avulsion or compression (disc); symptoms related to level; good prognosis.
V. PHYSICAL EXAMINATION
In suspected cervical spinal injuries, a brief screening examination should be administered to assess the magnitude of the injury at the scene of the accident.
Observation. The position of the head and neck at impact should be noted to categorize the mechanism of injury.
History
In the on-site evaluation after cervical spinal injury, the examiner must first apply the ABCs of resuscitation. When unconsciousness follows neck injury, basic life-support measures should be applied. (Note: Hyperextension of the neck should be avoided during these efforts.)
If the patient is awake and alert, a history is taken to establish whether consciousness was lost at any point during or following the injury (amnesia for the event to be checked).
The location and quality of any pain (neck, arms, shoulders, hands, back, or legs) is noted.
Numbness patterns must be defined. In the event of complaints of numbness, the clinician must define whether the pattern is global (all extremities) or partial (upper vs. lower extremities) and whether it was transient or is persistent.
Motion. If the patient is not amnesic for the event, did not lose consciousness, and has no self-reported neurologic loss, the clinician can then encourage the patient to attempt active range of motion of the neck without assistance. If significant pain is encountered, the neck should be immobilized and the patient further evaluated.
Neurologic examination
Sensory examination. This examination should include tests of sharp versus dull discrimination, light-touch sense, deep pressure, vibration, and position sense in all extremities.
Motor examination. Muscular strength should be assessed and graded in all limbs. Reflexes should also be graded in all limbs.
Rectal examination. In cases of spinal cord injury, the rectal examination is the most important part of the examination and can help the clinician discriminate between complete and incomplete spinal cord lesions after the resolution of spinal shock. (Note: This procedure, although important, is not part of the on-site evaluation.)
VI. RADIOGRAPHS
Standard cervical spinal radiographs include anteroposterior, lateral, oblique, and odontoid views. If there is no evidence of fracture or dislocation, a flexion–extension view of the cervical spine is also obtained. Active neck flexion and extension are always performed by the patient without assistance and should not be pushed beyond the patient’s reported comfort level. The spinal column is considered unstable when vertebral body subluxation in excess of 3.5 mm or an angular deformity of 11 degrees or more exists.
Supplemental radiographs consist of pillar views to evaluate the lateral masses. Computed tomography (CT) scan can be used to detect subtle fractures and evaluate the spine for rotatory subluxation. Magnetic resonance imaging (MRI) is also very useful in the evaluation of soft-tissue abnormalities (ligamentous disruption and disc protrusion).
VII. TREATMENT
The most important aspect of the management of cervical spinal injury is immobilization. Neck immobilization should be maintained until a definitive diagnosis has been made. For example, football-related cervical spinal injuries are managed by transporting the patient (with helmet in place) on a backboard. The patient is log rolled onto a backboard with vigilant head stabilization. The face guard is left in place unless respiratory difficulty is encountered, in which case it is removed. The neck is never moved passively until a fracture or dislocation is ruled out. (Note: In cases of spinal cord injury, the administration of methylprednisolone intravenously should be strongly considered because this agent has been shown to improve neurologic recovery if given within 8 hours of injury.)
VIII. COMMON CERVICAL SPINAL PROBLEMS
“Burners” or “stingers.” These injuries represent a stretch of the brachial plexus with a transient loss of motor power and transient pain radiating down the arm(s). This phenomenon usually occurs in football players. Most often, the symptoms are temporary and usually resolve within 1 to 2 minutes. The individual can generally return to play the day of injury. With more severe brachial plexus injuries (i.e., persistent pain or weakness), nerve damage may result. Consequently, neurologic loss and pain will persist. These athletes cannot return to play and should be carefully examined in a controlled, off-field setting.
Ligamentous sprain. These injuries occur when a force moves a joint through an abnormal range of motion. This condition presents with localized neck pain and muscle spasm. The neurologic and radiographic examination findings are usually normal. Treatment consists of immobilization (semirigid collar), local heat, muscle relaxants, anti-inflammatory medicines, and restriction of activity. Athletes can return to play when the symptoms resolve.
Cervical spinal fractures—stable. These types of fractures include C1 burst fractures (Jefferson’s fracture), most odontoid fractures, traumatic C2 spondylolisthesis (hangman’s fracture), compression fracture of a vertebral body without comminution, and spinous process fracture (clay shoveler’s fracture). Most of these fractures are treated with rigid immobilization (halo vest) until healing is complete.
Cervical spinal fractures and subluxation—unstable. Cervical spinal subluxation/dislocation usually presents with neurologic loss. These injuries require immediate immobilization and should ultimately be reduced. MRI is useful for assessing soft-tissue damage in these cases. Cervical traction or surgical reduction and stabilization are frequently indicated.
Cervical disc herniation. This phenomenon is uncommon in young athletes but may be seen in axial compression injuries sustained during rugby or football. Again, MRI is the best diagnostic modality for assessing patients for potential disc problems.
THORACOLUMBAR SPINERepetitive stresses to the ligamentous and bony supports of the thoracic (dorsal) spine can result in an overuse syndrome with subsequent acute or chronic back pain. Spondylolysis is
a unilateral or bilateral fracture of the pars interarticularis. This lesion is frequently nontraumatic and may represent a congenital lesion or stress fracture. However, spondylolysis can occur acutely, especially in gymnasts, weight lifters, and football linemen. Spondylolisthesis is a fracture of the pars interarticularis, which is associated with translation of one vertebral body over another. It is frequently observed in the lumbar spine, especially at the L5–S1 junction.
a unilateral or bilateral fracture of the pars interarticularis. This lesion is frequently nontraumatic and may represent a congenital lesion or stress fracture. However, spondylolysis can occur acutely, especially in gymnasts, weight lifters, and football linemen. Spondylolisthesis is a fracture of the pars interarticularis, which is associated with translation of one vertebral body over another. It is frequently observed in the lumbar spine, especially at the L5–S1 junction.
I. HISTORY
Pain is usually localized to the lower back and, less commonly, to the buttocks and posterior thighs. Radicular symptoms are uncommon.
II. PHYSICAL EXAMINATION
Hamstring tightness is common. Point tenderness may be noted along the dorsal thorax.
III. DIAGNOSTIC STUDIES
Oblique views of the lumbosacral spine usually demonstrate the spondylolytic lesion (lucency at the neck of the “Scotty dog”). A stress fracture of the pars interarticularis that is not obvious on plain radiographs may be demonstrated by means of bone scintigraphy.
IV. Treatment
consists of local measures, including heat, nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and rest during the acute period. Modification of activity or bracing is usually required. Surgical fusion is indicated only in cases of severe spondylolisthesis or unrelenting pain.
SHOULDERSports that require repetitive overhead arm motion (baseball, racquet sports, and swimming) place unusual stresses on the supporting structures of the shoulder. Injuries to the shoulder capsule, rotator cuff musculature, biceps tendon, scapular stabilizers, and shoulder musculature are common. Most of these problems are discussed in Chapter 21. Additional shoulder problems, unique to overhead athletes, are discussed in this section.
Little Leaguer’s shoulder typically affects adolescents and teenagers and represents a separation of the proximal humeral epiphysis. The observed physical abnormality is likely to have been caused by repetitive forces associated with the acceleration phase of the pitching cycle (extreme humeral abduction and external rotation to forward flexion and internal rotation).
History. These typically young patients complain of arm pain during and after throwing.
Radiographs reveal widening of the proximal humeral growth plate and demineralization and fragmentation adjacent to the epiphyseal plate. Occasionally, loose bodies are noted in the glenohumeral joint.
Treatment is conservative. Patients are prohibited from throwing until clinical and radiographic healing has occurred.
Rotator cuff tendinitis usually occurs as a result of overuse or in cases of subtle glenohumeral subluxation. It responds well to conservative measures (ice packs, NSAIDs, and rest). Rehabilitation is most effective in relieving symptoms.
Posterior capsular tears, which occur in throwers, can result in ossification of the posterior capsule near the glenoid labrum. These lesions occur secondary to traction on the capsule during the acceleration and follow-through phases of the pitching cycle. Treatment initially consists of rest, NSAIDs, strengthening exercises, and restriction of pitching.
Internal impingement syndrome typically occurs in baseball pitchers. Lesions occur at the posterosuperior margin of the glenoid in the undersurface of the rotator cuff tendons (partial tears). These lesions are attributed to impingement of the rotator cuff on the bony margin of the glenoid during the cocking phase of the pitching motion (abduction and external rotation). Treatment is conservative (activity modification and NSAIDs). Recalcitrant cases may require debridement of the lesion.
INSTABILITY. Global instability (anterior, posterior, and inferior) of the shoulder can occur in overhead athletes because of microtrauma to the shoulder capsule. The shoulder usually does not frankly dislocate but rather feels “loose” to the patient. Many cases can be treated with physical therapy; surgical stabilization may be necessary in severe cases.
ELBOWThe diagnosis and treatment of problems of the elbow require an understanding of the anatomy and function of the joint.
I. ANATOMY AND FUNCTION
The elbow is a hinge joint. Elbow flexion and extension occur at the articulation of the humerus and ulna. Rotation takes place at the proximal radioulnar and radiocapitellar joints.
II. JOINT STABILITY
During valgus stress, primary stability is derived from the bony fit of the ulnohumeral and radiocapitellar joints. Secondary stability is derived from the restraint provided by the medial (ulnar) collateral ligament. The lateral (radial) collateral ligament and the anconeus muscle provide some resistance to varus loads; however, bony constraint is much more important in resisting these forces. Most throwing activities subject the elbow to valgus stress.
III. COMMON ELBOW PROBLEMS
Overhead athletes (throwers and tennis players) place tremendous, repetitive valgus forces on the medial side of the elbow. These forces result in the application of compressive forces on the lateral elbow during the acceleration phase of throwing. Forceful extension during follow-through (extension overload) leads to posterior compartment lesions (loose bodies and osteophytes). Medial elbow tension-overload injuries include acute valgus instability and chronic valgus instability, both of which can be complicated by ulnar neuropathy.
Acute valgus instability
Flexor mass tears. These lesions occur at the elbow in association with sudden forced wrist flexion and pronation. Tenderness and pain at the point of the tear are noted with resisted wrist or finger flexion. Partial tears are initially treated with rest, ice packs, and NSAIDs. This is followed by resistive exercises at the wrist. Complete tears present with a palpable soft-tissue defect distal to the flexor muscle origin and may require surgical reattachment.
Medial (ulnar) collateral ligament tears (acute). These lesions present with pain and tenderness during valgus stress of the elbow. Laxity with valgus testing at 30 degrees of flexion confirms the diagnosis. MRI is useful in distinguishing between complete and partial medial collateral ligament injuries. Partial tears are treated with ice packs, rest, early motion, and a gradual return to full activity. Complete tears require surgical repair/reconstruction in high-level athletes who wish to continue throwing.
Little Leaguer’s elbow. Repetitive valgus stresses in children can cause epiphyseal avulsion of the medial epicondyle rather than ligamentous rupture. Treatment is usually conservative (ice packs, rest, and early motion).
Athletes at risk are pitchers, catchers, and javelin throwers.
Chronic valgus instability is common in athletes involved in throwing sports. Medial collateral ligament laxity develops slowly over time and occurs secondary to the microtrauma associated with repetitive throwing. Traction spurs at the distal insertion of the medial collateral ligament and calcification within the ligament can occur. Chronic ligamentous laxity may require surgical excision of calcified deposits and spurs, debridement, and reefing of the medial collateral ligament or reconstruction with use of the palmaris longus tendon. Loose bodies can also form within the elbow joint as a result of this condition, so that elbow arthroscopy is generally performed on patients undergoing reconstruction of the medial collateral ligament.
Ulnar neuropathy can develop secondary to ulnar nerve compression at or near the elbow (cubital tunnel). Affected patients present with pain along the ulnar groove, with radiation of pain and paresthesias into the fourth and fifth fingers. In most patients, Tinel’s sign is positive at the elbow. Electromyographic and nerve conduction studies may be required to confirm the diagnosis. Studies have demonstrated that this condition often accompanies chronic laxity of the medial collateral ligament of the elbow. Initial treatment consists of rest and NSAIDs. Decompression of the cubital tunnel and nerve transposition may be required.Related posts:
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