22/03/2016
COMMON SPORTS INJURIES
• Overview:
COMMON SPORTS INJURIES
Assessment and Management
• Update common tendinopathies
• Overview of tendinopathy
• What works and when
• What doesn’t work and why
• Update knee injuries
• Knee pain and injury in the older athlete
• Meniscal tear – when to operate and when not
• Osteoarthritis – treatments between the fish oil and joint replacement
Gavan White
Sports Doctor
Synergy Sports Medicine
• Update hip and groin injuries
• Differentiate hip joint pain from non-hip joint pain
• Hip joint pain and current concepts for treatment
• Non-hip joint related pain and current concepts for assessment and treatment
TENDINOPATHY
• Tendinopathy is NOT an inflammatory process
• Continuum concept
• Reactive tendinopathy
• Reaction to injury with protein synthesis, swelling, stiffness and pain
• Returns to normal
• Dysrepair
• Repeated injury causes reactive change and some failure of healing
• Some ability to heal and some degenerative change
• Chronic degenerative tendinopathy
• Failure of cellular healing, apoptosis, collagen break down, tears
• No ability to return to normal
• Often progressive
TENDINOPATHY
• Reactive:
• Increased cellular activity with ground substance and collagen production
• Pain usual and restricts activity
• Natural healing and strengthening if allowed to heal over 7-10 days
• Treatment
• Relative rest
• ‘Triple therapy’ – NSAIDs, Green Tea, Doxycycline (or Fish oil)
• Corticosteroids work well – Paratenon injection, iontophoresis
• AVOID
• Strengthening exercises, Ultrasound therapy, Massage
TENDINOPATHY
• Reactive to early degenerative
• Reduced cellular activity, ground substance and collagen production
• Apoptosis
• Mixed reactive on degenerative picture
• Treatment
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Mechanotransduction – strengthening exercises
Ultrasound therapy, cross fibre massage
Extracorporeal shock wave therapy
Aautologous blood injection/Platelet Rich Plasma injection
? Vitamin D
• AVOID
• Corticosteroids – Catabolic and reduce cellular protein synthesis
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22/03/2016
TENDINOPATHY
• Chronic degenerative
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Failure of above treatments to work
Failure of sustained cellular activity
Apoptosis
Break down in ground substance and collagen leading to tears
• Treatment
• Autologous tenocyte implantation
• Surgery
• Avoid
• Corticosteroids, especially injected into the tendon
• Overloading the tendon
TENDINOPATHY
QUESTIONS?
Knees next
KNEE PAIN
• There are many and varied injuries and conditions that affect the knee
• Acutely swollen knee after injury = Haemarthrosis
• Swelling within 1-2 hours of an injury
• Consider ACL tear, Patellar dislocation, Intra-articular fracture, Haemophilia
• Slowly developing swelling = effusion
• Swelling over 12-24 hours
• Consider meniscal tear, chondral injury
• No swelling at all = ? Injury outside the joint
• Consider collateral ligament tear, fat pad injury, contusion, bone bruise
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22/03/2016
KNEE PAIN
• Assessment after injury
• A good history of the mechanism of injury can make the diagnosis easier
• A good knee examination should provide a diagnosis
• Unless Haemarthrosis and pain makes examination difficult
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Valgus and Varus stress test helps diagnose collateral ligament injury
Lachmann and anterior draw test help to diagnosis ACL and PCL injury
McMurray’s, Thessaly and ? Appley’s grind help diagnose meniscal injury
Patellar glide, compression and apprehension test help diagnose PFJ pain
• Haemarthrosis requires X-ray to exclude fracture
• Ultrasound his little use in knee assessment – only collateral ligaments and
tendons
• MRI is required to diagnose meniscal, cruciate ligament and chondral injuries
KNEE PAIN
• Knee pain in the older athlete (35+) and older non athlete (50+)
• Increasing chance of chondral wear and osteoarthritis
• Meniscal tears are often degenerate rather then traumatic
• Role of arthroscopy
• Good evidence to show that arthroscopic ‘clean up’ is not helpful in OA
• Unless chondral flap repeatedly catching
• Reasonable evidence to show that arthroscopy is only as effective as exercise
for meniscal tear in the setting of OA
• Unless definite symptoms of catching, locking, loose body
• Increasing use of ‘injectables’ in athletic OA (and OA in general)
• Good evidence evolving for some and not for others
KNEE PAIN
• Injectables
• Steroid injection – short lived or minimal benefit
• No positive effect in the long term and probably negative effect
• Viscosupplements – good level of improved pain and function
• Evidence of being superior to placebo
• Limited duration of benefit and variable
• Platelet Rich Plasma Injection – good level of improvement
• Evidence of being superior to placebo
• Duration of benefit exceeds 18-24 months
• Mesenchymal Stem Cell injections – unclear evidence base
• Variable papers relating to comparison with viscosupplementation
• Unclear long term effect (safety)
HIP AND GROIN PAIN
• Assessing groin pain
KNEE QUESTIONS
• Important to differentiate hip joint pain from other causes of pain
Hip and Groin next
• If not hip joint, need to differentiate trochanteric pain from pubic region pain
• Once differentiated the origin of the pain, the causes become less complex
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22/03/2016
HIP JOINT PAIN
• Pain distribution
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HIP JOINT PAIN
• Causes of true hip joint pain
Groin pain – deep ache, sharp and pinching
Referred pain into the anterior thigh
Referred pain in the knee
Worse with weight bearing, twisting, squatting, sitting leaning forward
Difficult to put shoes on
• Examination
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Femoro-acetabular impingement
Labral tear
Degenerative joint disease
Inflammatory arthritis
Other – Femoral neck stress fracture, AVN, Transient synovitis, Transient
osteoporosis, etc
• Pain at extremes, particularly flexion, adduction, internal rotation
• Pain triggered by FADIR provocation test
• Pain specifically triggered with inner or outer quadrant testing +/- click
• Typical of Labral tear
HIP JOINT PAIN
• Current treatments
• Femoro-acetabular impingement
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Reduce height of leg kick and cross body kick
Strengthening of the hip girdle muscle to prevent uncontrolled impingement
Consider one off steroid injection to settle synovitis
Consider surgical shaving of the CAM lesion – if minimal joint OA
• Labral tear
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Reduce height of kick, extreme, end range movements (dance)
Strengthen hip girdle muscles
Consider one steroid injection
Consider surgical repair or debridement of the tear
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22/03/2016
TROCHANTERIC REGION PAIN
• Pain distribution
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• Causes of Trochanteric region pain
Lateral groin/over greater trochanter
Referred pain into the gluteal region
Referred pain down the lateral thigh and may extend to lateral calf
Worse lying on the side, getting up from sitting, going up hills
• Examination
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TROCHANTERIC REGION PAIN
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Trochanteric bursitis
Gluteus medius/minimus enthesopathy and tear
Bony source of pain in the trochanter
In the older age group, mainly gluteal enthesopathy
• Treatment
Normal hip joint range of movement
May get trochanteric pain with FABER
Tender over the greater trochanter and insertion of Gluteus medius and minimus
May have pain and/or weakness with resisted abduction
• In the young athlete can inject the bursa with steroid
• In the older or recurrent treat as per tendinopathy
• Shock wave therapy, autologous blood injection, PRP
• If tear, treat the same but consider ATI and surgery if large tear
MEDIAL GROIN PAIN
• Medial groin pain is generally related to the pubic bones and attachments
• Pain distribution
• Medial groin (may be bilateral)
• Referred into the inner thigh(s), lower abdomen, perineum
• Worse with running, jumping, possibly coughing, lifting
• Persisting ache after exercise
• Examination
• May be pain with hopping on affected leg, cough
• Normal hip movements
• May be
MEDIAL GROIN PAIN
• Causes of medial groin pain
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Adductor origin tendinopathy or tear
Rectus abdominus tendinopathy or tear
Conjoint tendon tear (Sportsman’s hernia)
Pubic stress syndrome (Osteitis pubis)
Don’t forget
• True hernia, prostatitis, etc
• Pain with adductor squeeze
• Pain with resisted sit-up or double legged lift
• Tender over Adductor origin, pubic symphysis/tubercle, conjoint tendon
MEDIAL GROIN PAIN
• Treatment
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Complex!!
Consider all causes are the same problem, presenting mainly at one site
Stress overload from adductors, through the pubic symphysis to abdominal wall
Important
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Markedly reduce exercise/ sport for 6-8 weeks
Well designed physiotherapy program
Consider a steroid injection of the main problem (symphysis, adductor origin, etc)
Graded return to sport
Possible use of Prolotherapy, PRP, repeated steroid injections
Possible surgery
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22/03/2016
HIP AND GROIN PAIN
QUESTIONS?
No more to come
Thanks
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