SPORTS INJURY JAIPUR TALK I Dr.RAJAT JANGIR JAIPUR

SPORTS INJURIES
Dr.RAJAT JANGIR
Consultant Arthroscopy and Sports Injury
Ligament and Joints Clinic, Mansarovar, Jaipur
MS Ortho (Ahmedabad)
Fellow Arthroscopy(S.Korea)
Dip Sports Med IOC

But for some people—particularly those who overdo or who don’t
properly train or warm up—these benefits can come at a price:
sports injuries.

Knee injuries (55%) >Shoulder> Ankle
The most common injuries are
 strains or sprains (41%),
 broken bones (20%),
 bruises or superficial injuries (19%)

India: Data Sparse
 Journal of Athletic Enhancement: Prevalence of Sports Injuries in
Adolescent Athletes Ieleni Sreekaarini, KMC Manipal

Sports injury pattern in school going children Chandigarh
Dr.Ravi Gupta

French gymnast Samir Ait Said snapped his leg during a pommel horse

Australian javelin thrower Kim Mickle dislocated her right shoulder

The ‘immediate’ cause may seem obvious
 but sports medicine clinicians think beyond the ‘immediate cause’

Treatment ABC
 Airway
 Breathing
 Circulation

Initial treatment of injuries
PRICE
 Protection
 Rest
 Ice
 Compression
 Elevation

Protection
 Take player away from field to avoid further injury as soon as possible

Rest
 Remove player from field
 Rest injured area
 Immobilize area
 Why?
 Reduces further tissue damage
 Reduces blood flow
 Allows for full assessment of injury

Ice
 Ice bag, pack
 Ice water bath
 15 mins/ 5 times a day
 Why?
 Cool the area which constricts blood vessels, reduces blood flow and fluid
leakage, less swelling, pressures and pain

Compression
Compress injured area with
Elastic bandage
Move distal to proximal
Why?
External pressure reduces fluid leakage and bleeding into tissues
Provide support the area

Elevation
 Elevate area above height
 Why?
 Reduces bleeding as blood has to flow up hill
 Gravity helps swelling to move towards lymph nodes

No HEAT
 Includes
 Hot packs
 Spas
 Saunas
 Why?
 Increases blood flow to area therefore increases swelling

No ALCOHOL
 Includes most things adults enjoy after a game of sports
 Why?
 Thins blood which increases swelling
 Adds toxins to already injured area

No RUNNING
 Includes running as well as any exercise that is painful
 Why?
 Increases in tissue damage
 Overload to other area as compensation

No MASSAGE
 Rub down
 Massage
 Mobilizations
 Why?
 May increases tissue damage
 Increases blood circulation to the injured area

 Overhead Athelete
 Hamstring strain
 Plantar Fascitis
 Ankle Sprain
 ACL Injury

Kinetic chain
Mc Mullen and Uhl 2000

Lesions
• Specific to the overhead athlete
- Internal impingement
- UPS (Unstable Painful Shoulder)
• Not specific to the overhead athlete
- SLAP tears
- Anterior Instability
- Sub-acromial impingement
- Fractures/ dislocations

Pathology
• Cardinal lesions
• Articular sided rotator cuff tears
• Postero-superior labral lesions
• Landmark article: Walch G, Boileau P, Noel E, et al. Impingement of the deep surface of the
supraspinatus tendon on the posterosuperior glenoid rim: an arthroscopic study. J Shoulder Elbow
Surg. 1992;1:238-245.

Symptoms
ation
• Pain during maximal abduction/ external rot
• Posterior joint line / shoulder girdle pain
• Progressive decrease in velocity. Loss of control /
performance.
• Symptoms of anterior instability (?)

Signs
• Posterior glenohumeral joint-line tenderness
• Loss of Internal Rotation
• Excessive External rotation
• Special tests
- for SLAP, biceps, Cuff and instability

Specific test
• Internal impingement test
• Place arm in Abduction 90-110, Max ER, Ext 10-15.
• Deep posterior shoulder pain
• In non contact injuries; 95% sensitivity, 100%
specificity
Meister K, Buckley B, Batts J. The posterior impingement sign: diagnosis of rotator cuff and posterior labral tears
secondary to internal impingement in overhand athletes. Am J Orthop. 2004;33:412-415.

Specific test
• Jobe’s Relocation test
• Abduction and external rotation causes posterior joint
line pain.
• relieved by anterior pressure

UPS: Unstable Painful shoulder
• Symptoms of pain
• No symptoms of instability.
• Imaging / Arthroscopy suggestive of instability
• Apprehension test caused pain
Retrospective Mean 38 months FU
• 95% satisfied 75% return to sports.
The unstable painful shoulder (UPS) as a cause of pain from Unrecognized Anteroinferior
instability in the young athlete.
J Shoulder Elbow Surg. 2011 Jan;20(1):98-106.
Boileau P, Zumstein M, Balg F, Penington S, Bicknell RT. Hôpital de L'Archet, Nice,
France.

Decision making
• Level of participation
• Sport
• Motivation
• Season
Surgeon
Therapist Coach
Patient

Beware!
!• Cuff tears in asymptomatic individuals
• Labral tears in asymptomatic athletes !
• Pathologies which do not corelate with clinical
picture !
• Low sensitivity of scans to pick PT cuff tears
Avoid Excessive reliance on scans

Role of surgery
• After exhausting rehab options.
• “Trial of Therapy” vs “early surgery” = overuse vs
acute trauma

Rehab
• Core Strength
• Scapular dyskinesia
• Manage Internal rotation deficit
• Restore RC force couple

Surgical input
Precision strike and not carpet bombing!

Hamstring strain
 Lateral:
Biceps femoris (BF) lh – sh
 Medial:
 Semimembranosus (SM)
 Semitendinosus (ST)
Tendon insertion
 Proximal conjoined of ST and BF(A)
 SM long prox tendon (B)
• Distal insertions
Lateral lh-BF
• Fibular head
Medial
SM: deep, flat, wide
ST: superficial

Injury types
 Direct injury – Contusion – Laceration
 Indirect injury (muscle strain)
Most common in sports
High recurrence rate

Indirect injury
 High speed(1) – Eccentric
 Combination?
 Slowstretch(2)
Passive outer range stretch – Prolonged recovery time

Diagnosis
 Inspection
 Pain on:
– Stretch
– Contraction
– Palpation (83% BF LH, 12% SM, 5% ST*)
 Additional imaging may guide diagnosis and prognosis#

MRI or US?
 Ultrasound
Low costs
Dynamic imaging
 MRI
More sensitive small/deep lesions
Less rater dependent

 MRI indication and timing: experts opinion
< 3 days trauma MRI preferred
‘by experts and literature for acute hamstring injuries in elite athletes based
on its greater sensitivity for minor injuries’
Kerkhoffs et al. 2012

History Positive parameters
 Moderate evidence:
• Shorter self predicted time to RTP
 Limited evidence:
• Shorter time to RTP predicted by the clinician

Negative history parameters
 Limited evidence:
• Type of sport (dancers vs sprinters)
 • Higher VAS score at injury
 Conflicting evidence:
• Stretching type of injury mechanism (vs. sprinting type)
• ≥ 1 day to walk pain free

Advise for daily practice, reporting MRI
 Absence of edema (Grade 0 quicker RTP),
 Grade 3 delayed RTP
 Involvement of proximal tendon (and describe the central tendon)

Therapy
 Physical therapy / rehabilitation
 Additional medical therapies
 Surgery

Return to play
 Decision affects:
Athlete’s availability
Performance
Re-injury rate
 Clinician reputation

Return to play
• No consensus about safely RTP
• No single test as the gold standard.
Orchard J, Best TM, Verrall GM. Return to play following muscle strains. Clin J Sport Med Off
J Can Acad Sport Med 2005;15:436–41.
Heiderscheit BC, Sherry MA, Silder A, et al. Hamstring strain injuries: recommendations for
diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther 2010;40:67–81.
Mendiguchia J, Brughelli M. A return-to-sport algorithm for acute hamstring injuries. Phys Ther
Sport 2011;12:2–14.

 Can we use MRI for RTP decision making ?
 Follow-up MRI has been suggested to support decisions

Plantar Fasciitis
 Gradual onset of deep, aching heel pain localized to the plantar medial heel
 AM pain on arising & after getting up from sitting
 Start-up pain improves after ambulation but may worsen w/ prolonged
activity

Plantar Fasciitis
Risk Factors
 Repetitive stress in athletes
 Obesity
 Cavus foot – accommodates poorly to stresses
 Over-pronated pes planus – excessive laxity stresses the PF
 Tight heel cord
 Heel spur: Often coincidental
 NOT itself the etiologic factor Occurs in FDB, not the PF

Plantar Fasciitis Non-op Treatment
 Successful in more than 90% of patients
 Complete relief of symptoms may take months to > 1 yr
 Achilles tendon & PF stretching (latter more effective)
 Heel cushions/ Shoe inserts / orthoses
 Activity modification Oral NSAIDs

Plantar Fasciitis
Non-op Treatment
If no improvement after 6 – 8 weeks
 Night splints
 Casting
 Steroid injection
 After weeks to months w/o improvement
 Limit to2 or 3as may weaken PF & resulting rupture
 Avoid injecting the fat pad as atrophy may result
 Consider w/u for rheumatologist

Plantar Fasciitis
OPERATIVE Treatment
 AOFAS position statement recommends min 6 mo and preferably 12 mo
nonoperative treatment
 Subtotal PF release ± decompression of first branch of lateral plantar nerve
 Complete release → iatrogenic flat foot w/ lateral midfoot pain
 Endoscopic release limited

“Matched Anatomic” Single Bundle

Advantages- Anatomic Reconstruction
 Supplementing both AM & PL
 Controlling both AP & Rotatory Instability
 Drilling femoral Tunnel Independently of tibial tunnel

ADVANTAGES
 LESS PAIN
 QUICKER RECOVERY
 INSTRUMENTATION SPECIFICALLY DESIGNED FACILITATE A MORE
PREDICTABLY ANATOMIC ACL RECONSTRUCTION
 Disadvantages
 INCREASED COSTS DUE TO THE SPECIAL INSTRUMENTS
 TECHNICALLY DEMANDING WITH LEARNING CURVE FOR SUGEON

SPORTS INJURY JAIPUR TALK I Dr.RAJAT JANGIR JAIPUR

SPORTS INJURY JAIPUR TALK I Dr.RAJAT JANGIR JAIPUR

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