Chapter 27 Sports injuries

Case 27.1

History

Tomislav is a 24-year-old amateur boxer. During a competition 1 week ago, he was struck on the jaw by an opponent and knocked to the floor (but did not lose consciousness). Over the following few hours he developed pain in the left side of his jaw and face, experienced some light headedness and reported occasional tingling on the left side of his tongue.

The symptoms have settled over the last few days, but he continues to feel some pain in his jaw and the tingling in his tongue seems to occur when he yawns. He has some pain when chewing, but he also reports pain when turning his head in either direction. He has had a dull headache all day, and has not returned to training since the competition. Tomislav has not complained of balance disturbances, nausea or coordination problems.

Tomislav is otherwise fit and healthy, although he does report a history of aching in his neck, which he regularly ‘cracks’ to provide relief.

There is no history of cardiovascular or neoplastic disease in his family.

He does not use recreational drugs, steroids or other stimulants. He only occasionally drinks alcohol.

Questions

1. Using only this information, list possible causes of Tomislav’s clinical presentation. Justify your answer.

2. Why was Tomislav asked about:

a loss of consciousness and headache

b the relationship of the pain to movement

c cardiovascular or neoplastic disease?

3. Describe how you would perform a cranial nerve ‘quick scan’.

4. What do you need to examine in this patient? Justify your answer.

Physical examination

General	Tomislav is fit and lean, appears to be in discomfort, but otherwise is lucid, aware and calm
Vitals	• Pulse rate/min	50
	• Respiratory rate/min	15
	• Blood pressure mm Hg	120/80
	• Height (cm)	175
	• Weight (kg)	70
	• BMI	22.9
	• Temperature (degrees C)	37.6
HEENT	• Cranial quick scan normal • Pupillary reflexes and other UMN signs normal • Jaw tender to palpation bilaterally, mildly swollen on the left but moves symmetrically and with full strength • No apparent contusions or bruises, apart from some swelling around both zygomas from the boxing match. Bony palpation of the skull is normal though sensitive around left mastoid
	• Neck tender to palpation in suboccipital region bilaterally • Rapid active neck rotation to left and right repeated several times aggravates tingling sensation in tongue on the left side • Vertebral artery test normal
Chest	No cardiomegaly, heart sounds normal, no murmurs, chest clear
Abdomen	Soft, non-tender, no masses
Neurological	Unremarkable

Questions

5. What information can you obtain from these findings? Can you now narrow your differential diagnosis?

6. Explain the significance of the neck rotation causing tongue tingling in light of your differential diagnosis.

7. Tomislav is referred to a medical practitioner. What investigations should the patient have done? Why? What would you expect, based on the physical examination findings?

Investigations

• Plain X-ray: mild loss of cervical lordosis, no degenerative changes detected. Functional studies showed cervical flexion and extension within normal range. No abnormality at the odontoid.

• Computerised tomography: deemed by the patient’s medical practitioner as being unnecessary at this time.

Questions

8. What is your final diagnosis, based on these results? Justify your answer.

9. List some of the features of post-concussion syndrome.

10. Describe the ringside action plan for an unconscious boxer.

11. Compare and contrast some of the more common intracranial haemorrhages.

Case 27.2

History

Richelle, a 23-year-old female personal assistant, presents to your office with posterior left shoulder pain and weakness of the left shoulder. Four weeks prior she suffered a left shoulder dislocation whilst practising ju-jitsu. She reports landing on the posterior aspect of the left shoulder and upper arm after being thrown to the ground by her opponent. An anterior left shoulder dislocation was confirmed with plain radiography at the local emergency department. The dislocation was immediately reduced and she has not experienced any spontaneous re-dislocations since.

The pain and swelling has dissipated, but she complains of experiencing persistent posterior shoulder pain. The pain has a constant burning sensation, and is localised to the inferior half of the medial border of the left scapula. No particular movements seem to aggravate the pain, however, she reports that combined elevation and external rotation is uncomfortable. She reports difficulty elevating her left arm, to the extent that she can only use her right hand when washing her hair.

Apart from the oral contraceptive pill and occasional analgesics, she is currently not taking any other medications. She is also taking omega-3 and iron supplements, the latter for iron-deficiency anaemia diagnosed about 9 months ago. She is otherwise fit and healthy, and there is no family history of connective tissue disorders.

Questions

1. Compile a problem list for this patient.

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