Common Sports & Overuse Injuries

Common Sports & Overuse Injuries David G. Liddle, MD, FACP Assistant Professor of Orthopedics & Rehabilitation Assistant Professor of Internal Medicine Vanderbilt University Medical Center Nashville, TN

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Objectives Review pertinent anatomy and pathology associated with common sports injuries and MSK conditions Review historical and physical exam findings associated with these conditions Review imaging findings relevant to these causes of pain and discuss a rationale for appropriate use of diagnostic tests Review the best evidence available to the guide treatment of these conditions

Non-Arthritis Shoulder Pain Non-Operative Subacromial Impingement Subacromial Bursitis Adhesive Capsulitis Frozen Shoulder Biceps Tendonitis Operative &/or Non-Op Rotator Cuff Tear Acute, Known Injury Surgery Chronic, Unknown Injury Non-Op Proximal Biceps Tendon Tear Labral Tear Glenohumeral or AC Joint Arthritis AC Joint Sprain Separated Shoulder Shoulder Instability

Proximal Biceps Tendon Tear Proximal Distal www.eastbaysportsmed.com http://images.ookaboo.com/photo/m/bicepstendon10_m.jpg images.rheumatology.org

Proximal Biceps Tendon Tear History Pain and/or pop at anterior shoulder but usually not painful after initial event May have bruising at anterior shoulder that tracks distally Exam Popeye Deformity with defect proximal and bulge distal ROM usually normal May be Tender To Palpation at site of tear Weakness on elbow flexion with hand in supinated position Usually normal strength with hand at neutral or pronated

Proximal Biceps Tendon Tear Imaging None required unless history of trauma If trauma, XR to r/o fracture MRI usually does not change management Treatment Reassurance Surgery if Relative strength deficit is intolerable or affects work/play Deformity is cosmetically unacceptable

AC Joint Sprain

AC Joint Sprain History Fall onto/blow to superolateral shoulder with ADducted arm Pain radiates from superior shoulder to lateral neck and upper trapezius Pain with reaching, especially across body Pain can prohibit pushups, bench press, and overhead lifting Aching rest pain No change in shoulder pain with Neck ROM Exam Tender To Palpation at AC joint May have step off at AC Joint Pain with Cross-Arm Adduction test Likely won t have secondary Impingement signs unless they present late

AC Joint Sprain Imaging 3-4 views of the Shoulder AP Int. & Ext. Rotation & Axillary +/- Scapular-Y view Degree of Separation determines type of dislocation Treatment Type I and II Non-Op Sling initially and Ice PO NSAIDs or APAP or Narcs (rare) AC joint CS Injection Rehab Avoid developing Impingement Type III Non-Op or Surgery If distal clavicle overrides acromion on Cross Arm ADduction test Surgery Type IV-VI - Surgery AC Joint Reconstruction www.aafp.org

AC Joint Sprain XR Grade 2 Grade 3 Grade 4 Grade 5

Glenohumeral Instability http://www.imageinterpretation.co.uk/shoulder.html http://emcow.files.wordpress.com/2012/09/shoulder-disloc1.jpg http://www.intechopen.com/source/html/40393/media/image6_w.jpg

Glenohumeral Instability History Subluxation Popped back in w/o specific Tx Dislocation Someone else reduces or specific technique used to relocate joint Direction of Instability follows humeral head ABduction-ER = Anterior (90%) Abduction = Inferior Forward Elevation = Posterior Exam Arm hanging limp at side Inability to reach across body Inability to externally rotate arm Anterior Instability Apprehension/Relocation tests Sensitive & Specific for Fear, Not Pain Inferior Instability Sulcus on Traction tests Posterior Instability Posterior Jerk test

Anterior Instability Apprehension and Relocation Tests http://www.chiro.org/links/full/shoulder_dislocation_in_young_athletes.html

Posterior & Inferior Instability Posterior Jerk Test Sulcus Sign with Traction Test http://i1.ytimg.com/vi/gpucikfkuze/maxresdefault.jpg http://o.quizlet.com/y8h2wk5imz4g0bpp.9v3pw_m.jpg

Glenohumeral Instability Imaging 4 views of the Shoulder AP Int. & Ext. Rotation & Axillary & Scapular-Y view Axillary view prevents missing a posterior dislocation Classification Treatment Reduce Dislocated Joint Level I Intra-articular lidocaine is preferred to IV sedation Same success; Less complications (0.9 vs. 16.4%) Fitch RW, Kuhn JE. Acad Emerg Med 2008 Sling Immobilization Level I & II Ext. Rot. may reduce recurrence; Req. 3 wks. (1/4 studies) Itoi et al. JBJS 2007 Sling vs. Surgery (No studies Rehab vs. Sx) Level I Non-Op Tx has higher risk of recurrence (47 vs. 16%) Kirkley et al. Arthroscopy 1999 Kuhn JE, Dunn WR et al. J Shoulder Elbow Surg. 2011

Lateral Epicondylopathy

Background Degenerative process involving the origin of: Extensor tendons at the lateral elbow Often repetitive, sport or occupation relate

Lateral Epicondylitis Clinical History Point tenderness over the lateral epicondyle and extensor complex Pain upon gripping or rotation Pain with backhand Usually recreational player Most who get it, don t play tennis Kibler, Clinical biomechanics of the elbow in tennis: implications for evaluation and diagnosis, Med and Sci in Sports and Exercise, 2004.

Physical Exam In Lateral Epicondylitis Lat. epicondyle & extensor mass Pain with resisted extension Pain with passive terminal flexion

Imaging

Treatment

Anatomy Review

Regional Approach To Hip Pain Anterior Hip Arthritis Iliopsoas Bursitis Hip Flexor Strain Osteitis Pubis Femoral Neck Stress Fracture Femoroacetabular Impingement Hip Fracture Lateral Greater Trochanteric Bursitis Hip ABductor Tendonopathy Meralgia Paresthetica Posterior Hamstring Strain Ischial Bursitis Sacroiliac Joint Dysfunction Lumbar Radiculopathy/Sciatica Piriformis Syndrome Depends/Other Snapping Hip Syndrome Hip ADductor Strain Apophysitis / Avulsion Fractures Pelvic Stress Fractures Iliac Crest Contusion

XR To Order If They Can Walk, They Can Stand! Standing AP Pelvis, Lateral of the involved Hip If Fall/Trauma w/ Pelvic Pain - Add Pelvic Inlet/Outlet Views and Lateral of Sacrum

Hip Pain Radiating Patterns

Greater Trochanteric Bursitis

Greater Trochanteric Bursitis History Lateral hip pain Pain sleeping on affected side or lying on unaffected side without (or relieved by) pillow between knees Chronic/insidious onset more likely than acute w/o h/o trauma Pain may radiate to lateral thigh but no numbness or paresthesias Exam TTP at greater trochanter Weakness in gluteus medius/deep hip rotators Weak on affected side with Trendelenburg Stance or Single-Leg Squat tests Often present bilateral but asymmetric Worse on sympt. side

Greater Trochanteric Bursitis Imaging Standing AP Pelvis and Lateral of affected side Usually normal but my see enthesopathy at greater trochanter Treatment PT for hip/core strengthening Voltaren gel Corticosteroid Injection Bursectomy (rare/salvage)

Hip ABductor Tendonopathy

Hip ABductor Tendonopathy History Lateral and/or posterior hip pain Posterolateral pain crossing legs Pain lateral with IR or ADduction Pain sleeping without (or relieved by) pillow between knees Chronic/insidious onset most likely No radiating symptoms Exam TTP at Gluteus medius, esp. at insertion site on posterior greater trochanter Pain lateral with passive IR Pain with resisted ER and ABduction Weakness in gluteus medius/deep hip rotators Weak on affected side with Trendelenburg Stance or Single-Leg Squat tests Often present bilateral but asymmetric Worse on sympt. side

Hip ABductor Tendonopathy Imaging Standing AP Pelvis and Lateral of affected side Usually normal but my see enthesopathy at greater trochanter or tendon insertion May show calcific tendonopathy Treatment PT for hip/core strengthening Corticosteroid Injection Ultrasound Guided for tendon sheath or calcific tendonopathy Tenoplasty or Tendon repair

Calcific Hip ABductor Tendonopathy

Hip ABductor Calcific Tendonopathy Treatment U/S Guided Lavage & CS Injection; Debridement if too large or failed CSI

Muscle Strains

Hip Muscle Strain History Pain at mid belly, origin, or insertion of muscle Usually acute eccentric load or repetitive stress Both Acute and Chronic presentations are common Exam TTP at muscle or tendon Myotendonous Junction common Pain with Passive Stretch Pain with Resistance Examples Hip Flexor P-Ext & R-Flex Hip Adductor P-ABd & R-ADd Hamstring P-Flex & R-Ext of Hip as well as P-Ext & R-Flex of Knee

Hip Muscle Strain Imaging Standing AP Pelvis and Lateral of affected side Usually Normal but must r/o avulsion fractures Treatment Rehab Strengthen > Stretch LOE 1 & 2 Eccentric > Concentric LOE 1 & 2 Progressive Agility and Trunk Stabilization > Static Stretch and Strengthen LOE 2 Proprioceptive Neuromuscular Facilitation Stretching > Conventional Stretching LOE 1

Femoroacetabular DJD History Anterior, deep pain in the hip that is constant Hopeless pain Worse with activity, sitting, or upon standing/start-up (+) Rest Pain Radiate to groin/medial thigh Usually insidious onset May have h/o trauma or h/o pain/limp as child No change in hip pain with lumbar ROM Exam Limited P/AROM on IR/ER/Flex Pain with passive Int/Ext Rot. Reproduce pain with log roll No pain with Straight-Leg Raise

Log Roll Test Intraarticular Pathology

Femoroacetabular DJD Imaging Standing AP Pelvis and Lateral of affected side Joint space narrowing, osteophytes, and acetabular rim and/or femoral head and/or femoral head flattening

Femoroacetabular DJD Non-Operative Physical Therapy Weight Loss Hip carries 3-8x Body Weight Pain Medicine NSAIDs Tylenol (APAP) Narcotics U/S Guided Steroid Injections Viscosupplementation Level I Not Clinically Significant Migliore A, Arthritis Res Ther. 2009;11(6) Richette P, Arthritis Rheum. 2009 Mar;60(3) Operative Non-Joint Replacement Total Joint Replacement

Anatomy Review

Surface Anatomy Medial Lateral

XR To Order If They Can Walk, They Can Stand! Bilateral Standing AP, Bilateral Sunrise, and Lateral

Differential Diagnosis For Knee Effusions Injury/Event Fracture Dislocation Cruciate Tear Bone Bruise Meniscus Tear No Injury/Event DJD Septic Arthritis Gout/CPPD PVNS Chondromatosis Inflammatory Arthritis Reactive Arthritis Spontaneous Hemarthrosis

Leg MUST Be Straight Knee Effusions If not, fluid will hide in Popliteal Fossa Direct Palpation Feel femoral condyles at the patella Compress suprapatellar pouch Feel for fluid femoral at the condyles Visualize Fluid Wave Milk Fluid from the anterior-medial joint line Push fluid out of superolateral suprapatellar pouch Watch for wave at anterior-medial knee

Medial Collateral Ligament Sprain

Medial Collateral Ligament Sprain History Pain at medial knee Relieved by resting leg on lateral foot with ER hip Usually with lateral blow to knee or fall with knee falling into valgus Exam TTP at MCL on medial joint line and/or above or below joint line Graded based on degree of laxity on valgus stress Grade 1 Pain but No Laxity Grade 2 Pain and Laxity at 20 flexion Grade 3 Laxity in Full Extension +/- Pain

Medial Collateral Ligament Sprain Imaging Bilateral Standing AP, Bilateral Sunrise and Lateral of affected side Findings = Normal r/o fracture, esp. in skeletally immature Treatment Initial Therapy Straight leg raises and full range of motion Double-hinged knee brace Not Knee Immobilizer PT for hip/core/quad rehab Return To Play Full Strength, ROM, & Speed for all things activity requires Grade 1 2-4 weeks Grade 2 4-6 weeks Grade 3 6-8 weeks;? Surgery

Medial Meniscus Tear

Medial Meniscus Tear History Pain at affected joint line Worse with incr. activity, sitting, or upon standing/start-up May have catch/release/locking symptoms Usually starts with weight bearing + twist injury May result from both an event or a process Exam TTP at posterior medial (NOT anterior medial) joint line Consider Duck Walk test if Hx convincing but exam equivocal McMurry s is only 50-60% sensitive and specific May or May Not have an Effusion

Medial Meniscus Tear vs. MCL Sprain MCL Divides Medial Joint Line Into Ant/Post MCL Pain tracks Vertical or Perpendicular joint line MMT Pain tracks Horizontal or Parallel to joint line 95% of MMT are in the POSTERIOR Horn

Medial Meniscal Tear Imaging Bilateral Standing AP, Bilateral Sunrise and Lateral of affected side r/o or determine severity of DJD Consider MRI if joint line tenderness AND <50% joint space narrowing on XR Don t Create an MRI Bomb! Treatment PT for hip/core/quad strengthening and quad/hamstring flexibility, CS Injection Arthroscopy If >50% medial joint space narrowing, MMT Tx changes from: Non-Op 75% symptom relief 50% Surgery 90% symptom relief 70%

Meniscus Tears Therapy Evidence Level 1 Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and metaanalysis. Khan et. al. CMAJ. 2014 Aug 25 Conclusion There is moderate evidence to suggest that there is no benefit to arthroscopic meniscal debridement for degenerative meniscal tears in comparison with nonoperative or sham treatments in middle-aged patients with mild or no concomitant osteoarthritis. A trial of nonoperative management should be the firstline treatment for such patients.

XR Review Meniscus Tears and Arthritis Clinical Meaningful Difference >50% Joint Space Narrowing (JSN) = Changes Arthroscopic outcomes & favors rehab as initial Tx Favors Non-Op 50% JSN No Injury Less Active No Mechanical Symptoms Favors Surgery <50 % JSN Injury/Event Active &/or Young Mechanical Symptoms

Iliotibial Band Friction Syndrome

Iliotibial Band Friction Syndrome History Pain at lateral knee Worse with incr. activity, sitting, or upon standing/start-up Worst in mid-range of motion Prefer to walk down stairs/hills with peg/straight leg May radiate to lateral leg or distal/lateral thigh Common in runners Exam TTP at lateral femoral condyle or Gurdy s tubercle Weak Hips/Core Weak on affected side with Trendelenburg Stance or Single-Leg Squat tests

Iliotibial Band Friction Syndrome Imaging Bilateral Standing AP, Bilateral Sunrise and Lateral of affected side Findings = Normal Treatment PT for hip/core strengthening and IT band stretching Foam Rolling CS Injection at IT Band and Lateral Femoral Condyle Bursa

Ankle Sprains https://heidenortho.com/types-ankle-sprains/ https://www.gothamfootcare.com/services/ankle-sprain

Which Ligaments Involved? Vanderbilt Bone and Joint

Anatomy Lateral Joint Stabilizers Anterior Talofibular Ligament (ATFL) Calcaneofibular Ligament (CFL) Posterior Talofibular Ligament (PTFL) Medial Joint Stabilizers Superficial and Deep Deltoid Ligaments Bone Stabilizers Anterior Tibiofibular Ligament (AITFL) Posterior Tibiofibular Ligament (PITFL) with deep portion Interosseous Ligament Vanderbilt Bone and Joint

Anatomy Syndesmosis Contributions AITFL: 35% IOL: 22% PITFL: 40% IOM: <10% Primary Resistors to External Rotation and Lateral Talar Shift Medial malleolus Deltoid Ligament Vanderbilt Bone and Joint Borrowed from Dr. Michael Khazzam

21 yo injures his ankle Swollen Unable to bear weight Case Vanderbilt Bone and Joint

Case Exam TTP lateral malleolus tip and anterior tib/fib area NT over proximal fibula Negative Squeeze test Positive ER test Anterior Drawer and Talar Tilt unable to assess Vanderbilt Bone and Joint

Ottawa Ankle Rules Pooled Analysis 97.6% sensitive 31.5% specific 0.08 Neg LR Bachmann BMJ 2003;326:1 Level II Vanderbilt Bone and Joint

Ankle Instability Tests Anterior Drawer Optimum position 90 o knee flexion 10 o ankle plantarflexion No one measurement is diagnostic, more important side to side Kovaleski J Athl Train 2008;43(3) and Croy et al. J Orthop Sports Phys Ther 2013;43(12). Vanderbilt Bone and Joint Lynch J Athl Train 2002;37(4):406

Ankle Instability Tests Anterolateral Drawer Pivots around Deltoid 100% sens/spec compared with 75%/50% with Anterior Drawer Phisitkul Foot Ankl Int 2009;30(7):690. Cadaver study Lynch J Athl Train 2002;37(4):406 Vanderbilt Bone and Joint

Ankle Instability Tests Talar Tilt Neutral and plantar position Inversion force Lynch J Athl Train 2002;37(4):406 Vanderbilt Bone and Joint

What about the Syndesmosis? MRI proven injuries Sensitive tests Single leg hop: 89% Tenderness: 92% Dorsiflexion/ER test: 71% Specific tests Pain out of proportion: 79% Squeeze test: 88% Sman et al. BJSM epub 11/19/2013. Vanderbilt Bone and Joint Lynch J Athl Train 2002;37(4):406

So we have an ankle sprain AAOS guidelines Rest Ice Compression Elevation NSAID s Vanderbilt Bone and Joint

How about Functional immediately? Compared walking boot to functional Acute presentation MRI proven tears Functional Better AOFAS scores Back to work quicker Pain and instability equal Prado et al. Foot Ankle Int, epub 2014. Vanderbilt Bone and Joint

Focus on strength, neuromuscular control Grade I and II sprains Time to Move PT Accelerated (1 st week) better outcomes than waiting a week 8 week home proprioceptive 11% AR reduction in re-injury NNT = 9 Bleakley BMJ 2010;340:c1964 (Level I), Hupperets BMJ 2009;339:b2684 (Level 1), and image from Sports Health 2010;2(6):460. Vanderbilt Bone and Joint

Effective Taping = Braces Braces cheaper 15-50% reduction in ankle sprains Prevents recurrences Should be coupled with neuromuscular training Reduce incidence but not severity Ankle Braces Verhagen et al BJSM 2010;44 and Janssen et al. BJSM 2014, epub Vanderbilt Bone and Joint

Plantar Fasciitis

Plantar Fascia Anatomy Originates at the anteriomedial aspect of the calcaneus Spreads broadly as it extends distally to divide into 5 digital bands at the MTP joints Inserts into the base of the proximal phalanx of each toe

Mechanics Relatively inelastic structure Maximal elongation is 4%. Windlass effect High tensile forces concentrated at the calcaneal origin during the toeoff phase Raises the arch of the foot during the push-off phase of walking Gastrocnemius-soleus muscles Contract in the toe-off phase while the body weight is on the forefoot and the PF is under tension http://charlieweingroff.com/wp-content/uploads/windlass.png

Bow and bowstring Mechanics

Mechanics Walking Heel Strike = 110% body weight Running Heel Strike Force = 200% body weight

Calcaneal Exostoses DuVries HL, Arch Surg, 1957 The concept of physical impingement into the plantar fat pad was promoted Williams PL, et al, Foot Ankle, 1987 75% of patients with heel pain had heel spurs Asymptomatic patients had a 63% incidence of heel spurs Davies MS, et al, Foot Ankle Int, 1999 50% of patients with heel pain had heel spurs

Runners and PF Up to 10% of runners affected D maio, Sports Med and Rehab Series, 1993 Novices especially at risk Threshold of 40miles/wk Fredericson and Misra, Sports Med, 2009 Long distance runners comprise a higher percentage than the population at large of those undergoing surgery for PF Riddle DL, et al, JBJS, 2003

Riddle DL, et al, JBJS, 2003 Variable Odds ratio 95% Confidence Interval Ankle dorsiflexion 0 23.3 (compared with individuals who had >10 of dorsiflexion) 4.3-124.4 BMI 30 kg/m2 Majority of time spent on feet during workday 5.6 (compared with individuals who had a BMI of 25 kg/m2) 3.6 (compared with individuals who did not spend time on their feet) 1.9-16.6 1.3-10.1 Recreational Runner 2.8 (compared to nonrunners) 0.4-22.7

Clinical Diagnosis Gradual onset of pain in the inferior heel Usually worse with the first step in the morning or after a period of inactivity Pain lessens with gradual increase in activity but may worsen toward the end of the day with increased duration of weight-bearing Associated paresthesias uncommon

Clinical Diagnosis History of increased intensity and/or mileage Change in footwear or surface Other risk factors present Standing Occupation Obesity Pes Planus Pain can be bilateral Approximately 1/3 of cases

Inspect stance/gait Clinical Diagnosis Pes planus, pes cavus Maximal tenderness over the anteromedial aspect of the inferior heel or midfoot Decreased ankle dorsiflexion due to Achilles tightness Passive dorsiflexion of ankle and MTPs may exacerbate symptoms Windlass mechanism

DDx Plantar Heel Pain Bone Soft tissue Site Nerve (entrapment or compression) Diagnoses Calcaneal stress fracture - positive squeeze test; x-ray may show sclerosis Bone bruise - Hx of trauma, generalized pain over inferior heel Infection Cancer - deep bone pain, nocturnal Paget s disease Fat-pad atrophy - elderly, usually no morning pain, atrophy evident Bursitis Tarsal tunnel syndrome (posterior tibial nerve) First branch of the lateral plantar nerve S1 radiculopathy Nerve to abductor digiti quinti Neuropathic pain

Treatment Plantar Fasciitis Nonsurgical: NSAIDs Injections LOE 2 Orthoses LOE 2 Heel Pads Physical therapy LOE 2 Night splints Walking casts Extracorporeal shock wave therapy (ESWT) LOE 1/2 Surgical Treatment Plantar fascia release

Footwear/Orthoses Orthoses may be helpful for runners with excessive pronation, leg length discrepancy, patellofemoral pain, plantar fasciitis, Achilles tendinitis, and shin splints Superfeet Powerstep

Prospective Cohort LOE II

Summary Conservative therapy should always be the first line of treatment More than 90% of cases respond to this approach by 1 year Plantar Fascia Stretching & PT, Orthotics, CS Injection supported by level I & II EBM Reserve ESWT for recalcitrant cases NOT for initial therapy Surgical treatment should not be utilized until all conservative measures are exhausted

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