Sports Injuries
Common injury questions:
How do I know I have been injured?
1. Pain that lasts more than 2 days
2. Symptoms increase with activity or return after a workout at the same or increased intensity
3. Symptoms decrease performance once warmed up
What is the best way to treat a new injury?
Immediate rest and ice. Ice 20 minutes on/20 minutes off as much as possible to control symptoms. Do not continue to work out or engage in activity through the pain. Determine the severity of the injury by pain level and mechanism of injury (ie gradual onset or trauma). Always seek medical attention if symtoms do not go away with rest for 1-2 days. Immediate care is advised if there is severe swelling, deformity, pain and/or instability. Always seek the advise of a doctor befpore using medication to control the symptoms.
What happens if I just continue to work through the pain?
Working through the pain is never a good idea. In the case of a torn labrum in the hip or the shoulder, instability can cause excessive wear and tear on the joint causing permanent damage. With tendonitis, the tissue consistency actually changes and weakens, allowing for more injury with less stressful activity. Working through the pain with a fracture, means you are stressing the fracture site and therefore more damage to the bone. Without the guidance of a medicAl professional, always let pain be your guide.
What is the chance of reinjury?
Even after all of the symptoms are gone, once an injury occurs there is a great chance that another one may occur if the surrounding areas in the body are not strengthened properly. When an injury occurs, the body alters it's movement patterns to take pressure off of the injured spot. This changes connections in the brain and creates habits that may not be identified on your own. With these changes, weakness can occur not only at the injury site but in the surrounding joints and places you at increased risk for a new problem. Statistics show, 80% of all people that injure their back, reinjure it within 1 year. It is imperative that you seek the help of a physical therapist, even if it is for 1-2 visits, to determine the strength of the injury site and the surrounding bodily regions and receive a indiviualized home program to strengthen the weak areas.
Tendonitis vs Tendinosis
Hamstring Injuries
Sports Concussions
NFL Concussion Trends
ACL Tears
Overhead Throwing Injuries
Tendonitis vs Tendinosis
Tendonitis is an acute, inflammatory condition in the tendon that occurs from strain or overuse. The injury disrupts the vascular tissue within the tendon and results in 3 overlapping phases:
Phase 1: Inflammation
Phase 2: Repair
Phase 3: Remodeling
Often this can be successfully treated with NSAIDS (anti inflammatories), rest and then proper exercise as directed by a physical therapist. At times, a cortisone injection is also appropriate.
But what happens if the tendon does not work its way through all three phases successfully? Tendonisis is the result of the tendon having an inability to heal properly. The mechanical properties of the tendon change and therefore it is unable to respond to the loads placed on it appropriately. There is hyper vascularity, hypercellularity, collagen disorganization, and abnormal ground substance deposition. (See picture below.)
Sports Health: A Multidisciplinary Approach 2009 1:284
So if there is no signs of inflammation, what causes the pain? No one has found a solid answer to this question, but there is an increase of glutamate, substance P and calcitonin gene-related peptide. These chemicals excite nerves in the region and transfer the pain sensation of pain to the brain.
The most common tendons in the body to suffer from tendinosis include the:
1. Achilles (heel)
2. Patella (knee)
3. Supraspinatus (shoulder)
4. Common wrist extensor tendons (elbow)
There is no well documented treatment for this condition, however, there are many physical therapists that have had great results with the follow treatment:
1. Eccentric exercise
2. Extracorporeal Shock Wave Treatment
3. Patelet Rich Plasma injection- performed by an MD
4. Nitric Oxide
5. Matrix Metalloproteinase
Hamstring Injuries
Acute hamstring strains comprise a significant amount of injuries suffered at a high school, collegiate and professional level. Sports most at risk include:
1. Track
2. Football
3. Rugby
4. Dancers.
During the years of 1998-2007, 1 National Football team experienced 85 hamstring injuries. This was the second most common injury for this team for those 10 years. The average number of days lost in athletic activity range from 8-25, depending on the severity and specific location of the strain. The biggest concern about these injuries is the high reinjury rate. 1/3 of all hamstring strains will be reinjured within the 1st two weeks after return to activity. This places a high amount of importance on rehabilitation and the proper progression to full activity.
The main cause of a hamstring strain is believed to occur during terminal swing of the gait cycle when the hamstrings are active, lengthening and absorbing energy from decelerating the limb. The greatest stretch is absorbed by the biceps femoris, the most lateral hamstring muscle, and therefore it is the most commonly injured hamstring muscle. Running injuries most often occur in the intramuscular tendon (aponeurosis) and the adjacent muscular fibers of the the biceps femoris (see MRI above). During rehabilitation, the hamstrings must be properly strengthened to support the high eccentric activity required during the terminal swing phase of gait.
Hamstring injuries that occur during kicking or dancing can occur with either slow or fast movements involving simultaneous hip flexion and knee extension. This movement places the most strain in the semimembranosus and its free tendon (vs the intramuscular tendon with the biceps femoris strain). Unfortunately this injury requires a longer rehabilitation period before returning to preinjury level of performance.
The primary goal of rehabilitation is to return the athlete to sport with a minimal risk of injury recurrence. This includes decreasing:
1. Swelling
2. Pain
3. Weakness
4. Loss of ROM
5. Addressing modifiable risk factors
The modifiable risk factors include:
1. Hamstring weakness and lack of flexibility
2. Strength imbalance between hamstrings and quadriceps muscles
3. limited quadriceps and hip flexor flexibility
4. Strength and coordination deficits in the pelvic and trunk regions
Some of the best strengthening exercises include:
1. Nordic
2. Single leg bridging with hamstring curl on the physioball
3. Windmill
JOSPT 2010 40;2: 67-81
Sports Concussion
There are 1.6-3.8 million sports related concussions/year occur in the US alone. At the high school level, concussions represent 9% of all athletic injuries. Most of the symptoms resolve in about 7-10 days and at this point the athlete may return to play with a clearance from their MD. According to the Third International Conference on Concussion Sport, a concussion describes any injury of physiologic dysfunction resulting from biomechanical forces acting on the brain. Symptoms often occur immediately following impact and may immediately worsen or gradually increase minutes or hours after the injury. Delayed onset of symptoms may occur from continued activity or as a result of a second impact.
Concussion vs Epidural Hematoma
What can make these injuries so dangerous is if they are misdiagnosed. If the patient is not appropriately examined, there may be a missed epidural hematoma, in which case the head injury could be life threatening. Concussions and epidural hematomas can produce the same symptoms initially, but if there is a change in the patient's level of consciousness for and extended period of time (1-2 hours post injury), or a skull fracture, the chances of it being a epidural hematoma goes up considerably. With an epidural hematoma, the athlete will have only mild symptoms for a time. Their initial symptoms may even improve, but as the hematoma grows, the increases intracranial pressure rises and the brain is compressed altering the athlete's function and their level of consciousness. Due to the severity of fractures or hemorrhages, then the return to play for the athlete is much more conservative.
Concussion and Seizure
On occasion a seizure may occur secondary to the head trauma (.2% of all mild brain injuries suffer from a seizure). If the onset of the seizure occurs minutes to hours after the injury, that is considered a marker for a trauma induced structural brain lesion or hemorrhage. Emergent care should be involved at this point and a CT scan obtained of the head.
Repetitive Concussions
Unfortunately, once a concussion has been suffered, it is much easier for an athlete to sustain another one in the same season. High school football players that suffer a concussion are 3 times more likely to suffer another one in the same season. Those that lose consciousness at the time of their concussion are 6 times more likely to suffer another one. Why is this? No definitive answer has been made, however the theories include that some people are just more genetically prone to concussions, or that the initial concussion makes the brain more susceptible to a second.
Sports Health Journal 2010; 2(3) :197-202
Recent NFL reports on concussion injury trends:
NFL seasons 2002-2007 vs 1996-2001: These two consecutive 6 year periods were compared to determine the concussion pattern of signs and symptoms, determine changes in circumstances associated with concussions and loss of participation from the NFL.
Tight ends 54% increase
Wide receivers 2.3% decrease
--- This may have occurred due to the change in the tight end offensive role on the field over those 6 years. They are running at higher speeds and getting hit at higher speeds during the 2002-2007 time frame vs the 1996-20012 time frame. they are also taking away some down field receptions from the wide receivers which may explain the slight decrease in their concussion reports.
Quarterbacks 1.6% decrease
Defensive linemen 41% decrease
--- This is probably due to the specific rule changes which protect quarterbacks from head impacts.
ACL Tears (Anterior Cruciate Ligament)
There are 70,000-90,000 ACL tears annually. 62-66% of them are sports related and often they are often non-contact in nature. 67% of the tears occur in individuals 16-29 years old, 26% occur in people 30-44 years old and the last 7% occur in people over the age of 45 years. The leading sports that ACL injuries occur are:
1. Football
2. Alpine skiing
3. Snowboarding (3-4 times more likely than skiing)
4. Soccer
Aside from the uncontrollable factors in a collision, the ACL injury is usually due to a combination of running and cutting, deceleration and cutting, planting foot and twisting or jumping and landing. The risk factors for non-contact injuries include poor neuromuscular control, hamstring/quadriceps strength ratio, multiple biomechanical factors, femoral intercondylar notch size and hormonal factors (females). Females have a significantly higher risk ratio for ACL tears than males in the following sports:
1. Volleyball 4:1
2. Soccer 6:1
3. Basketball 8:1
4. USNA military training 10:1
The signal from the tibial plateau bone bruise is intensified in
the extreme posterior ( non-weight bearing border while the femoral
condylar bruise does not extend to its posterior margin.
the extreme posterior ( non-weight bearing border while the femoral
condylar bruise does not extend to its posterior margin.
Unfortunately, many ACL tears do not occur in isolation. There is often a concomitant injury to the joint capsule, a meniscal tear (, or a neuromuscular insult to the surrounding tissue. Bone bruises ( see MRI above) occur in 70-92% of ACL patients, and this can lead to increased pain for months. The devastating fact about ACL tears is that they increase the rate of middle age osteoarthritis and can therefore decrease the person's ability to exercise and increase their risk of obesity later in their life.
Aside from the biological cost of an ACL tear, there is an extroardinary financial cost as well. for the insured patient, their co pays can cost up to 800-3000 dollars for out of pocket expenses. The uninsured patient may have costs upwards of $20,000-$50,000 for the doctor and surgical bills. Depending on your insurance coverage, physical therapy can also cost about $1000 dollars or more.
Preventative programs are on the rise and should be incorporated in all sports. Appropriate multi-component prevention programs that include dynamic balance and strength, stretching, body awareness, core and trunk control and lower extremity plyometrics have proven to decrease non contact ACL tears by 74%. If your child's team does not incorporate these things into their practice, parents can turn to performance training centers to assist in their child's sport development. If you live in the Orange County region in CA, check out Velocity Sports Performance Center in Irvine for an idea of what these preventative training programs include.
Overhead Throwing Injuries
Challenge: Acquire adequate laxity to achieve extreme ROM and sufficient stability to avoid subluxation and instability.
The total motion required from the shoulder is IR+ER=180.
IR= Internal rotation
ER=External rotation
Symptomatic shoulders often have a greater loss of IR vs the gain of ER making the total range less than 180 degrees.
Shoulder pain in throwers can be caused by any combination of the following:
1. Rotator Cuff pathology
2. Glenohumeral IR deficit
3. Capsulabral pathology
4. Impingement
5. Scapular dysfunction
6. Neurovascular
The essentials to a good throwing program are:
-Core conditioning
-Periscapular and Rotator Cuff strengthening
-Flexibility Programs
