25.

Rehabilitation & Sports Medicine - Dennis

J. Matthews, MD, & Pamela E. Wilson, MD
BASIC PRINCIPLES
Lo sviluppo di medicina di sport come una disciplina univoca è cresciuta dagli anni '80 in
risposta al corpo in espansione di conoscenza nelle aree di fisiologia di esercizio,
biomeccanica e medicina muscolo-scheletrica. Lo sviluppo rapido in idoneità fisica e in
attività fisica ha generato una necessità di addestramento specialmente in queste aree. Con
la popolarità corrente di bambini più giovani iniziali nell'atletica leggera più strutturato è
essenziale che il praticante abbia una conoscenza di medicina di sport.

Muscle fibers can be divided into three types. Slow twitch, or Type I, fibers have a tendency
to be smaller, are recruited in muscle contractions first, and are innervated by smaller motor
neurons. Fast twitch, or Type II, fibers make up white muscle and have a tendency to be
larger. They are recruited when the body needs to produce rapid muscle tension. In general
they produce more lactic acid than Type I fibers. An intermediate Type IIa fiber exists, called
fast oxidative glycolytic or FOG. Untrained individuals have a 50:50 proportion of Type I to
Type II fibers. Elite long-distance runners can have up to 90% Type I fibers. This apparent
adaptation raises the interesting question as to whether an athlete is genetically
programmed or can develop adaptations to be successful in sports.

Exercise generates specific effects on the cardiorespiratory system that include increased
VO2 max (maximum amount of oxygen that can be consumed), increased cardiac output,
reduced resting heart rate, and improved blood pressure responses.

Biomechanics, the study of movement and how the forces generated by the neuromuscular
system translate into these movements, integrates principles of biology and physics.
Through biomechanics we can understand the intricacies of movement and how these
movements affect athletic performance and result in injuries.

Types of Muscle Contraction

Le contrazioni dinamiche sono quei movimenti che portano a movimento di un orlo o

rotazione intorno a un asse congiunto. Contrazioni che possono essere divise più avanti in
contrazioni isotoniche e isocinetiche. In una contrazione isotonica, tensione costante è
generata durante la contrazione di muscolo; in una contrazione isocinetica, velocità costante
è mantenuta durante la contrazione. Esercizi Isotonici possono essere più avanti classificati
come sotto:

A. Concentric
In esercizi concentrici la forza di una contrazione di muscolo supera una resistenza esterna,
che porta ad accorciamento del muscolo. Questi muscoli accelerano un segmento distali
nella catena cinetica e sono quindi rimandati a movimenti di catena cinetica aperta. Un
esempio di un tale esercizio è quando i bicipiti si accorciano, durante quale i bicipiti si stanno
contraendo attivamente o accorciando per sollevare il peso.

B. Eccentric
In esercizi eccentrici, le contrazioni aumentano muscolo tensione associato ad allungare del
muscolo e sono utilizzate per rallentare un segmento distale nella catena cinetica. Tipo di
esercizio è esemplificato dal movimento accovacciante, in cui i quadricipiti allungano sotto
tensione per controllare movimento in giù.se il segmento terminale nella catena è fisso,
questo tipo di movimento è chiamato movimento di catena cinetica chiusa.

In contrasto con contrazioni dinamiche, le contrazioni isometriche aumentano tensione di

muscolo senza un cambiamento di lunghezza. Esempio di questo tipo di esercizio spingere
contro una superficie statica. Tensione è generata nel muscolo, ma non si verifica alcun
movimento.

Young JL, Press JM: The physiologic basis of sports rehabilitation. Phys Med Rehabil Clin N
Am 1994;5:9.

Strength Training

Strength is defined as the peak force that can be generated during a maximal single
contraction. Strength training is therefore the use of progressive resistance to improve an
athlete's ability to resist or exert force. This can be achieved by a variety of techniques
including body weight, free weight, or machine resistance. The benefits of weight training
programs are improved performance, endurance, and muscular strength. These programs
can be started in prepubescent athletes and if designed appropriately can be done safely
with minimal risk for injury. Tanner staging (see Chapter 30) helps to define readiness for
progression into more strenuous programs. Power lifting and weight lifting should be
restricted to those athletes who have reached or passed Tanner stage V. Individuals at
Tanner stage IV or less can safely participate in a strength training program that is
specifically and carefully designed for younger athletes. These programs incorporate
submaximal resistance with multiple repetitions. They can be generalized or sports specific.
Care should be taken to prevent injuries while using weight training equipment at home.

American Academy of Pediatrics: Strength training, weight and power lifting, and body
building by children and adolescents. Pediatrics 1990;86:801.

Faigenbaum AD: Strength training for children and adolescents. Clin Sports Med0019;4:593.

Jones CS, Christensen C, Young M: Weight training injury: A 20 year survey. Phys
Sportsmed 2000;28:7:61.

PREPARTICIPATION HISTORY & PHYSICAL EXAMINATION

The preparticipation medical examination is designed to evaluate children and screen for
potential medical problems that could occur during athletic participation. The objectives of
this evaluation are to establish baseline medical information, detect any medical condition
that may limit athletic participation, evaluate the athlete for preventable injuries, meet the
legal or insurance requirements of most states, assess the athlete's maturity, and make
recommendations for necessary protective equipment. The ideal timing of this examination
is in preseason, at least 4-6 weeks before training starts. This allows time for any needed
interventions by the physician.

Preparticipation History

The history is the most important part of the encounter. Many key elements need to be
explored with the athlete. The American Academy of Pediatrics (AAP) Sports Medicine
Section along with the American Academy of Family Practice (AAFP) have a standardized
sports history form (Figure 25-1 and Figure 25-1B). The history must include the following
areas:

A. Cardiovascular History
The physician should note any significant cardiac murmurs, chest pain, palpitations,
shortness of breath, or recent illnesses with chest pain. A family history of any members
who died suddenly needs to be explored. These questions are necessary to identify
potentially life-threatening cardiac lesions.

B. History of Hypertension
Any history of hypertension requires further investigation. The current guidelines for the
diagnosis of hypertension are blood pressure over 130/75 mm Hg in a child under age 10
years or blood pressure over 140/85 mm Hg in a child aged 10 years or older.

C. History of Chronic Diseases

Diseases such as reactive airway disease or exercise-induced asthma, diabetes, renal
disease, neurologic disorders, or hematologic diseases should be noted.

D. Musculoskeletal Limitations and Prior Injuries

The physician should explore abnormal range of motion or prior injuries that may affect
future performance.

E. Menstrual History in Females

The physician should pay particular attention to the so-called female athletic triad:
amenorrhea, eating disorders, and osteoporosis.

F. Nutritional Issues
The physician should record methods the athlete uses to maintain, gain, or lose weight.

G. Use of Performance Enhancing Agents

The physician should note the patient's use of anabolic steroids, stimulants, narcotic
analgesics, relaxants, β-blockers, hormones, diuretics, or blood doping.

Physical Examination

The physical examination should be focused on the needs of the athlete. It may be the only
time that an athlete has contact with a medical person, and it can be used to promote
medical awareness along with screening for physical activity. The AAP and AAFP have
generated guidelines for the approach to the preparticipation physical examination (see
Figure 25-1A and Figure 25-1B). The examination should include routine vital signs and
growth measures, as well as an assessment of Tanner staging and maturity. The
cardiovascular examination should include palpation of pulses, auscultation for murmurs,
and evaluation of the effects of exercise on the individual. The musculoskeletal examination
is used to determine strength, range of motion, flexibility, and previous injuries. Included is
a quick guide that can be used to screen for abnormalities in this area (Table 25-1). The
remainder of the examination should emphasize the following areas:

A. Skin
Are there any contagious lesions such as herpes or impetigo?

B. Visual
Are there any visual problems? Is there any evidence of retinal problems? Are both eyes
intact?

C. Abdominal
Is there any evidence of hepatosplenomegaly?

D. Genitourinary
Is there any history of testicular abnormalities or hernia symptoms?

E. Neurologic
Are there any problems with coordination, gait, or mental processing?

Recommendations for Participation

After completing the medical examination the physician can make recommendations to the
athlete on sports clearance. The options are unrestricted participation, limited participation,
or no participation. The AAP has established guidelines for health care providers to use when
medically related problems surface (Table 25-2).

American Academy of Pediatrics Committee on Sports Medicine and Fitness: Adolescents and
anabolic steroids: A subject review. Pediatrics 1997;99:904.

Lively MW: Preparticipation physical examination: A collegiate experience. Clin J Sport Med
1999;9:3.

Myers A, Sickles T: Preparticipation sports examination. Prim Care 1998;25:225.

West RV: The female athlete. The triad of disordered eating, amenorrhea and osteoporosis.
Sports Med 1998;26:63.

REHABILITATION OF SPORTS INJURIES

Participation in sports can have tremendous benefits for the individual involved. It provides
physical activity, acquisition of motor skills, and social opportunities. All sports participation,
however, carries an inherent risk of injuries. These injuries are classified as either acute or
chronic. Chronic injuries occur over time and are related to repetitive stress. These injuries
develop in response to overuse, repeated microtrauma, and inadequate repair of injured
tissue. Acute injuries, or macrotrauma, are one-time events that can cause alterations in
biomechanics and physiology. In response to an acute injury the body responds in a
predictable fashion. The first week is characterized by an acute inflammatory response.
During this time initial vasoconstriction is followed by vasodilatation. Chemical mediators of
inflammation are released and result in the classical physical findings of local swelling,
warmth, pain, and loss of function. This phase is essential in healing of the injury. The next
phase occurs over 2-4 weeks and involves repair and clean-up. Fibroblasts infiltrate and lay
down new collagen. This allows for repair of the injured area.

The management of acute sports injuries is geared toward optimizing healing and restoring
function. The goals of immediate care are to minimize the effects of the injury by reducing
pain and swelling, to educate the athlete about the nature of the injury and how to take care
of it, and to maintain the health of the rest of the body. The treatment for an acute injury is
captured in the acronym PRICE:

Proteggere la ferita da ulteriore danno (nastratura, vimini, parentesi graffe)

• Appoggiate l'area
• Ghiaccio
• Compressione della ferita
• Elevazione immediatamente

The use of nonsteroidal anti-inflammatory agents reduces the inflammatory response and
reduces discomfort. These medications may be used immediately after the injury.
Glucocorticoids should be administered judiciously. If administered inappropriately they may
prolong the acute phase of recovery. Therapeutic use of physical modalities, including early
cold and later heat, hydrotherapy, massage, electrical stimulation, iontophoresis, and
ultrasound, can enhance recovery in the acute phase.

The recovery phase can be lengthy and requires athlete participation. Initial treatment is
focused on joint range of motion and flexibility. Range-of-motion exercises should follow a
logical progression of starting with passive motion, then moving to active assistive, and
finally to active movement. Active range of motion is initiated once normal joint range has
been reestablished. Flexibility is sport specific and aimed at reducing tight musculature.
Strength training can begin early in this phase of rehabilitation. Initially only isometric
exercises are encouraged. As recovery progresses and flexibility increases, isotonic and
isokinetic exercises can be added to the program. These should be done at least three times
per week. As the athlete approaches near normal strength and is pain free, the final
maintenance phase can be introduced. During this phase the athlete will continue to build
strength and work on endurance. The biomechanics of sport-specific activity needs to be
analyzed and retraining incorporated into the exercise program. Generalized cardiovascular
conditioning should continue during the entire rehabilitation treatment.

COMMON SPORTS MEDICINE ISSUES AND INJURIES

INFECTIOUS DISEASES
Infectious diseases are common in both recreational and competitive athletes. These
illnesses have an effect on basic physiologic function and athletic performance. Given this
knowledge, physicians, parents, and coaches can adopt the common-sense guidelines listed
in Table 25-3.

American Academy of Pediatrics Committee on Sports Medicine and Fitness: Human

immunodeficiency virus (acquired immunodeficiency syndrome—AIDS virus) in the athletic
setting. Pediatrics 1991;88:640.

HEAD & NECK INJURIES

Head and neck injuries occur most commonly in contact and individual sports. The sports
with the highest incidence of brain injury are football, bicycling, baseball, horseback riding,
and golf.

Concussion is a temporary and immediate impairment of neurologic function and is

classified by length of unconsciousness, posttraumatic amnesia (PTA), and confusion.
Concussions are categorized as grade 1 (mild), grade 2 (moderate), or grade 3 (severe).
Return-to-competition guidelines have been developed by several resources. Table 25-4
reviews guidelines for return to play.

Second impact syndrome can occur in an athlete whose brain is not fully healed from the
first brain injury. It can result in death from loss of autoregulation and malignant cerebral
edema.

Cervical spine injuries are common at C3-C7 vertebrae for football injuries and C1-C2
vertebrae for other sports injuries. Axial loading of the spine is the main mechanism
involved. These injuries often result in spinal cord lesions and ligamentous injuries.
Atlantoaxial instability is common in children with Down syndrome and should be
screened for using cervical x-rays. A 4.5 mm or greater space between the odontoid and
arch is abnormal.

American Academy of Neurology: Practice parameter: The management of concussion in

sports (Summary statement). Report of the Quality standards subcommittee. Neurology
1997;48:581.

American Academy of Pediatrics Committee on Sports Medicine and Fitness: Atlantoaxial

instability in Down syndrome: Subject review. Pediatrics 1995;96:151.

Cantu RC: Guidelines for return to contact sports after a cerebral concussion. Phys
Sportsmed 1986;14:75.

Cole AJ, Farrell JP, Stratton SA: Cervical spine athletic injuries: A pain in the neck. Phys Med
Rehabil Clin N Am 1994;5:37.

Colorado Medical Society: Report of the Sports Medicine Committee: Guidelines for the
Management of Concussion in Sports (revised). Colorado Medical Society, 1991.
Brachial plexus injuries are common in football players and are caused by lateral bending
of the neck and subsequent stretching of the brachial plexus. Most injuries are neuropraxic
in nature (ie, resulting from a nerve stretch) and will resolve spontaneously. Players call
these injuries stingers or burners. The upper trunk is most often involved. Symptoms include
burning pain in a dermatomal distribution and weakness in the upper trunk muscles. Workup
includes a thorough neurologic assessment. If symptoms persist, then a diagnostic
evaluation should include cervical spine x-rays, computed tomography (CT) and magnetic
resonance imaging (MRI) scans, and electromyography (EMG). The athlete is excluded from
sports participation as long as symptoms are present.

Feinberg JH: Burners and stingers. Phys Med Rehabil Clin N Am 2000;11:4:771.

BACK INJURIES
Back injuries are a fairly common complaint even in the pediatric population. As children
have become more competitive in sports, the number of reported injuries has increased.
Sports with a fairly high incidence of back injuries are golf, gymnastics, football, dance,
wrestling, and weightlifting. Pain lasting more than 2 weeks indicates a possible structural
problem and needs to be investigated.

Herniated discs account for a small percentage of back injuries in children. These injuries
are almost unheard of in preadolescence. Most injuries occur at the L5-S1 vertebrae.
Symptoms include pain in sitting and forward bending, whereas extension of the spine may
relieve these symptoms. Pain may radiate down the lower extremity in a radicular pattern.
Evaluation includes neurologic testing, EMG, and CT and MRI scans. Treatment generally is
conservative because most back injuries improve spontaneously. The athlete can rest the
back for a short period and then begin on a structured exercise program. If symptoms
persist, then a short course of steroids may be indicated. Surgery is recommended only if
neurologic compromise persists.
Spondylolysis is an injury to the pars interarticularis. It occurs in just over 4% of the
population. Repetitive stress to this area results in fractures. The injury is common in
gymnasts, dancers, and football players. Spondylolysis occurs at L5 in 85% of cases. Pain
usually develops during an adolescent growth spurt. Back pain may radiate into the buttock
or thigh area. Extension of the spine increases pain. Evaluation includes an oblique x-ray
view of the spine in order to look for the so-called Scottie dog sign. Treatment includes rest,
stretching of the hamstrings, abdominal exercises, lumbosacral bracing, and occasionally
surgery.

If a bilateral pars injury occurs, then slippage of one vertebra over another
(spondylolisthesis) can occur. These injuries are graded on a scale of 1 to 4 based on the
percentage of slippage: Grade 1 involves 25% slippage; grade 2, 50%; grade 3, 75%; and
grade 4, 100%. Diagnosis is based on lateral x-rays, and treatment is symptomatic.
Asymptomatic athletes with less than 30% slippage have no restrictions and are followed up
on a routine basis. Slippage of 50% requires interventions of stretching hip flexors and
hamstrings, along with bracing or surgery.

Drezner JA, Herring SA: Managing low back pain: Steps to optimize and hasten return to
activity. Phys Sportsmed 1999;272:37.

Letts M, McDonald P: Sports injuries to the pediatric spine. Spine: State of the Art Reviews
1990;4:49.

SHOULDER INJURIES
In evaluating shoulder injuries it is necessary to look at both macro- and microtrauma.
Fractures and dislocations account for most macrotrauma. The balance of other injuries are
microtrauma related. Repetitive stress to the shoulder joint often causes impingement of the
supraspinatous tendon under the acromial arch and can result in rotator cuff disease.
Sports with a high incidence of this injury include baseball, swimming, tennis, and
gymnastics. Symptoms include night pain and increased pain with overhead activities.
Diagnostic workup includes plain x-rays and an outlet view to look for anatomic variability.
The rehabilitation of this injury is geared toward reduction of inflammation, improved
flexibility, and strengthening of the scapular stabilizers and rotator cuff muscles. This is
achieved by a progression of isometric followed by isotonic or isokinetic exercises. A
biomechanics evaluation can assist in the recovery process by building sport-specific skills
and eliminating substitution patterns.

Tythweleigh-Strong G, Hirahara A, Miniaci A: Rotator cuff disease. Curr Opin

Rheumatol0113;2:135.

ELBOW & FOREARM INJURIES

Injuries in the forearm are quite common and are often associated with repetitive trauma.
These injuries occur primarily in throwing sports and gymnastics.

Medial Elbow Pain

Medial elbow pain can have multiple etiologies, but one of the most common is medial
epicondylitis, an overuse injury caused by valgus stress at the elbow. Little league elbow
is a common and well-studied example. It consists of a group of abnormalities that develop
in young baseball pitchers. These abnormalities are secondary to the biomechanical forces
generated around the elbow during throwing. These forces can result in shearing,
inflammation, traction, and abnormal bone development. Pitching can be divided into four
phases: windup, cocking, acceleration, and follow-through. The acceleration phase is where
most forces are generated and most injuries occur. The symptoms are primarily pain,
performance difficulties, and weakness. The pain localizes to the medial epicondyle, which
may be tender to palpation. Wrist flexion and pronation increase symptoms. The different
phases of throwing should be analyzed to isolate when the pain appears. If pain is present in
all phases this may indicate a severe injury. Workup includes a series of elbow x-rays,
including stress films and comparison films, to look for widening of the epiphyseal lines and
MRI studies. Treatment of the acute injury includes rest. It is not uncommon for a player to
be benched for up to 6 weeks. Competition can be resumed once the player is
asymptomatic.

The key to treating this injury is prevention. Children should be properly conditioned and
coached in correct throwing biomechanics. There are guidelines for pitching limits in youth
baseball. Little League limits 10- to 12-year-old children to six innings per week and 13- to
15-year-old children to nine innings per week. With an older child, pitches should be limited
to 90-100 per game. Other causes of medial elbow pain include ulnar collateral ligament
injury, ulnar neuritis, apophysitis, and fractures.

Lateral Elbow Pain

Lateral elbow pain can be the result of a few unique problems in growing athletes. Panner's
disease is also caused by valgus stress at the elbow. It is a focal process in the capitellum
and occurs in players aged 7-12 years. The child presents with dull aching in the lateral
elbow that generally worsens when the child throws something. Swelling and reduced elbow
extension are usually present. X-rays show an abnormal capitellum with fragmentation and
areas of sclerosis. Treatment is conservative, using rest, ice, and splinting. The child can
return to play after the x-rays normalize.

The same type of pain in a 13- to 15-year-old athlete is usually osteochondritis

dissecans. This injury, basically an area of avascular necrosis in the capitellum, can result
in the formation of loose bodies. X-rays are needed in the diagnosis and help to classify the
injury into one of three categories. Treatment is based on the classification and can be either
conservative or surgical in nature. The child should be seen by an orthopedic specialist.

Lateral epicondylitis is common in racquet sports, particularly tennis. It is an overuse of

the extensor muscle in the forearm and causes pain in the lateral elbow. Pain is increased by
wrist extension. Initial treatment is aimed at inflammation control. Stretching and
strengthening of forearm muscles are the primary interventions during the subsequent
phases. Stroke mechanics may need to be altered and a forearm brace used to decrease the
forces in the extensor muscles.

Posterior Elbow Pain

Posterior elbow pain is not very common. Etiologies include dislocations, fractures, triceps
avulsions, and olecranon bursitis.

Abrams JS: Special shoulder problems in the throwing athlete: Pathology, diagnosis and
non-operative management. Clin Sports Med 1991;10:839.

Chumbley EM, O'Connor FG, Nirschl RP: Evaluation of overuse elbow injuries. Am Fam
Physician 2000;1:61:69.

Hall TJ: Osteochondritis dissecans of the elbow: Diagnosis, treatment and prevention. Phys
Sportsmed 1999;272:75.

Johnson EW: Tennis elbow misconceptions and widespread mythology. Am J Phys Med
Rehabil 2000;79:2:113.

HAND & WRIST INJURIES

All hand and wrist injuries have the potential for long-term, often serious disability and
deserve a thorough evaluation.

1. Hand Injuries

Distal Phalanx Injuries

Tuft injury requires splinting for 6 weeks or until the patient is pain free. If there is
significant displacement, then a K-wire can be used for reduction. Nail bed injury often
requires splinting and drainage of subungual hematomas.

Distal Interphalangeal Injuries

Mallet finger or extensor tendon avulsion occurs in ball-handling sports. The mechanism
of injury is a force applied to an extended finger. Treatment is splinting in extension for 6
weeks for fractures and 8 weeks for tendon rupture.

Thumb Injuries

Gamekeeper's thumb is an injury to the ulnar collateral ligament from forced abduction of
the metacarpal phalangeal joint. It is a common skiing injury. If a radiograph shows an
avulsed fragment is displaced less than 2 mm, a thumb spica cast can be used. If there is no
fragment and less than 35 degrees of lateral joint space opening, a spica cast for 6 weeks is
indicated. Surgery is required for more serious injuries.

Fractures

Boxer's fracture is a neck fracture of the fifth digit. These fractures can be treated by closed
reduction and casting for 3 weeks. A displaced fracture requires open reduction and internal
fixation.

2. Wrist Injuries

Most swollen wrists without evidence of instability can be splinted for several weeks. Radial
and ulnar fractures must be ruled out because these are fairly common in children.

Scaphoid fractures are caused by a force applied to a hyperextended wrist. If evidence of

snuff box tenderness and swelling is present, the wrist must be immobilized for 10 days and
then reassessed, even if x-rays are normal. A nondisplaced fracture requires at least 6
weeks of immobilization in a thumb spica cast.

Geissler WB: Carpal fractures in athletes. Clin Sports Med01;1563:1961.

Krasin et al: : Review of the current methods in the diagnosis and treatment of scaphoid
fractures. Postgrad Med J 2001;77:906:235.

Wang QC, Johnson BA: Fingertip injuries. Am Fam Physician 2000;1:61:69.

HIP INJURIES
Because the pelvis and hip articulate with both the lower extremities and the spine, this is
an area rich in ligaments, muscle attachments, and nerves. Injuries in young children are
rare, but sprains and strains are common.

Groin pull, or adductor strain, is generally caused by forced abduction as in running,

falling, twisting, or tackling. The associated pain is in the adductor muscle. There may be
pain with adduction or hip flexion and tenderness over the adductor tubercle. Treatment
includes rest, ice, protection, and strengthening of the muscle when it heals.

Quadriceps contusion is caused by a direct macroinjury to the muscle, resulting in

bruising, swelling, and pain. The anterior and lateral thigh regions are most commonly
injured. If the muscle remains firm on examination after 2 weeks, then x-rays of the thigh
should be done to rule out myositis ossificans. Myositis ossificans is an abnormal
deposition of calcium in the muscle that may be induced by aggressive stretching of the
muscle too early in the clinical course. Treatment is rest, ice, and protection for the first 24
hours. The knee should be kept in a fully flexed position. Two to three days after the injury,
range-of-motion exercises may begin in both flexion and extension. Once 120 degrees of
motion has been established and movement does not cause pain, the athlete may return to
competitive activity.

Hamstring strain is very common in multiple sports. The mechanism of injury is forced
extension of the knee. Examination reveals pain on palpation in the muscle or
musculotendinous junction, along with resisted knee flexion causing pain. Treatment is rest,
ice, and compression. The athlete can walk as soon as he or she can tolerate the activity. It
is particularly important to stretch the hamstring because, as a two-joint muscle, it is more
susceptible to injury than other types of muscle.

The bursa is a structure that allows for improved motion by reducing friction. When a bursa
becomes inflamed, movement is painful and may be limited. Areas susceptible to bursa
inflammation are the shoulder, elbow, patella, and hip. Trochanteric bursitis, causing pain
when the hip is flexed, often results from reduced flexibility of the iliotibial band and gluteus
medius tendons. It is best evaluated in a side-lying position, and pain is reproduced when
the hip is actively flexed from a fully extended hip. Initial treatment is to alter the offending
activity and then start a stretching program geared at the iliotibial band and hip abductors.
Corticosteroid injections may be used after conservative treatment has failed.

Most hip dislocations are in the posterior direction. Athletes with this injury classically
present with hip flexion, adduction, and internal rotation.

Hip dislocations in skeletally mature athletes are almost always associated with acetabular
and femoral neck fracture. The preadolescent, skeletally immature competitor may have an
isolated injury. This is a true on-field emergency, and the athlete should be transported to
the nearest facility that has an orthopedic surgeon available. Severe bleeding, avascular
necrosis, and nerve damage can result. Once reduction has been established in a
noncomplicated case, protected weight bearing on crutches for 6 weeks is recommended
followed by another 6 weeks of range-of-motion and strengthening exercises. An athlete
may return gradually to competition after 3 months.

Femoral neck fractures (stress fractures) are generally the result of repetitive
microtrauma. They commonly occur in track athletes who have increased their mileage.
Athletes with this type of injury present with persistent pain in the groin and pain with
internal and external rotation. Range of motion may be limited in hip flexion and internal
rotation. If plain x-rays are negative, then a bone scan is indicated. Treatment is based on
the type of fracture. A transverse fracture generally requires internal fixation to prevent
femoral displacement from occurring and potentially causing avascular necrosis. A
compression fracture is less likely to be displaced; treatment is conservative and involves
resting the hip until it heals. Cardiovascular conditioning can be maintained easily through
nonimpact exercises and activity.

Maffulli N: Lower limb injuries in children in sports. Clin Sports Med00;19:637.

KNEE INJURIES
Knee injuries are one of the most common problems evaluated by any practitioner. The
function of the knee is for mobility and stability. Knee movements include flexion, extension,
rotation, rolling, and gliding. The knee is stabilized through a variety of ligaments, tendons,
and the meniscus.

Anterior Knee Pain

The most common knee compliant is anterior knee pain. This complaint can have multiple
etiologies but always includes hip pathology as a possible source. Patellofemoral etiology is a
common cause of anterior knee pain. The differential diagnosis is quite extensive and
requires a thorough examination.

Patellofemoral overuse syndrome occurs in runners and in athletes participating in

sports with repetitive stress in the lower extremity. Classically, pain is located over the
medial surface and under surface of the patella. It is associated with swelling and crepitus of
the knee joint. The Q-angle often is increased. The Q-angle is measured by drawing a line
from the anterior superior iliac spine down to the center of the patella and then through the
tibial tubercle. The intersecting angle is the Q-angle. Normal is 14 degrees for males and 17
degrees for females. An increased angle can cause abnormal biomechanical forces to be
generated through the knee.

Plicae alares are normal synovial folds in the knee joint. If they become thickened or
fibrosed they can become entrapped. This happens with direct macrotrauma or repetitive
microtrauma. The athlete complains of snapping or popping in the knee. The knee pain is
worse with knee flexion and worsens progressively with activity. On examination the
hamstrings may be tight. Physical findings include localized tenderness and occasionally
popping palpable at 30-60 degrees of knee flexion.

Tendonitis of the patellar tendon is caused by overuse. The mechanism is repetitive loading
of the quadriceps during running or jumping. Osgood-Schlatter disease occurs in the
preteen and adolescent years. It is most common in boys aged 12-15 years and in girls aged
11-13 years. Pain usually is present at the tibial tubercle, and activities using eccentric I
vantaggi di programmi di addestramento di peso sono prestazioni migliorate, resistenza e
forza muscolare. quadriceps muscle movement aggravate the pain. The pain can become so
extensive that routine activity must be curtailed. X-rays may or may not show
abnormalities. Type 1 disease has no findings, whereas type 2 has evidence of
fragmentation of the tibial tubercle. Many other conditions can cause anterior knee pain and
need to be ruled out, including arthritis, complex regional pain syndrome, infections, and
neoplasm. Finally, chondromalacia patellae is an arthroscopic diagnosis and should not be
used as a clinical diagnosis.

Treatment of Anterior Knee Pain

As with any acute injury, control of inflammation is essential. This begins with rest and ice.
Alignment problems should be corrected with stretching and strengthening. Orthotics may
need to be used for correction of foot deformities. Quadriceps strengthening begins with
isometric exercises that progress to concentric programs. These include short arc vastus
medialis contractions, which are the last 10 degrees of knee extension. In the last part of
the therapy program eccentric loading of the quadriceps can be incorporated. During this
time the athlete should be working on endurance and cardiovascular conditioning. Knee
bracing is controversial, and the major benefits are proprioceptive feedback and patellar
tracking.

Lateral Knee Pain

Lateral knee pain is most commonly associated with a tight iliotibial band, which can lead to
tendonitis and bursitis. Pain over the lateral femoral condyle is present along with a
positive Ober's test. This test is done with the athlete in a side-lying position. The upper leg
is abducted and extended. The knee can be flexed or extended. The leg is then lowered
toward the bed. A tight iliotibial band will keep the thigh abducted. This is a positive Ober's
test. Treatment involves rest and stretching. Athletics should not be resumed until the
patient is pain free. This may take up to 6 weeks. Other sources of lateral knee pain are
popliteus tendonitis and biceps tendonitis.

Posterior Knee Pain

Posterior knee pain usually results from an injury to the gastrocnemius-soleus complex
caused by overuse. It can also include a Baker cyst, tibial stress fracture, or tendonitis of the
hamstring. Treatment is rest, ice, and strengthening exercises after symptoms have
improved.

Meniscal Injuries

The meniscus of the knee cushions forces in the knee joint, increases nutrient supply to the
cartilage, and stabilizes the knee. Most injuries are related to directional changes on a
weight-bearing extremity. Medial meniscus injuries have a history of tibial rotation in a
weight-bearing position. This happens frequently in ball-handling sports. Lateral meniscus
injuries occur with tibial rotation with a flexed knee. These injuries are uncommon in
children under age 10 years. The athlete with such an injury has a history of knee pain,
swelling, snapping, or locking or may report a feeling of the knee giving way. Physical
examination reveals joint line tenderness and a positive McMurray hyperflexion/ rotation
test. The diagnostic test of choice is MRI of the knee, although standard knee x-rays should
be included. Arthrograms are still used by some practitioners. Treatment involves surgical
repair of the torn meniscus. After surgery the athlete should not bear weight on the knee for
3 weeks. During this time, range-of-motion and strengthening exercises can be done.

Medial & Lateral Collateral Ligament Injuries

The medial and lateral collateral ligaments are positioned along either side of the knee and
act to stabilize it. They help to control varus and valgus stress applied to the knee joint.
Excessive varus or valgus stress causes stretching of the ligament, producing tears. Medial
injuries occur with a blow to the lateral aspect of the knee, as seen in a football tackle. The
athlete may feel a pop or lose sensation along the medial aspect of the knee. The
examination reveals an effusion and tenderness medially. A valgus stress test done in full
extension and 20-30 degrees of flexion will reproduce pain. Diagnosis is made by routine
and stress x-rays of the knee.

Treatment is almost always conservative. Initial injuries should be iced and elevated. A
protective brace needs to be worn, and full knee motion in the brace can be done after 7
days. Weight bearing is allowed, and a strengthening program can be started. The athlete
should use the brace until he or she is pain free and has full range of motion. The use of a
functional brace is often required when a player returns to competition. This is only
temporary until the ligaments heal properly.

Anterior Cruciate Ligament Injuries

The anterior cruciate ligament (ACL) has three bands and prevents anterior subluxation of
the tibia. The ACL is injured by deceleration, twisting, and cutting motions. The mechanism
of the injury involves force applied to the knee during hyperextension, with excessive valgus
stress and forced external rotation of the femur on a fixed tibia. Evaluation of the knee
begins with examining the noninjured knee. The Lachman test will provide information on
knee stability in relation to the ACL. All other structures of the knee need to be examined to
rule out concomitant injuries. Imaging of the knee includes plain x-rays along with MRI scan.

Treatment options include both conservative and surgical procedures. Conservative

treatment includes bracing, strengthening, and adjusting physical activity. The braces used
today enhance proprioception and control terminal extension. Surgical repair is quite
popular, and a patellar tendon graft is used frequently. Rehabilitation of the knee starts
immediately after surgery. A continuous passive motion machine is used postoperatively to
promote range of motion. Partial weight bearing is allowed in a brace that is set in full
extension as the quadriceps strengthen. After 2 weeks, partial weight bearing and walking
are started. The goals of the subsequent program are continued strength, muscle
reeducation, endurance, agility, and coordination.

Posterior Cruciate Ligament Injuries

The posterior cruciate ligament (PCL) runs from the medial femoral condyle to the posterior
tibial plateau and has two parts. Its main function is to prevent posterior tibial subluxation.
This is an extremely rare injury and occurs when the individual falls on a flexed knee while
the ankle is plantar flexed or when forced hyperflexion of the knee occurs. The examination
begins with the noninjured knee and proceeds to the injured side. Confirmatory testing
includes the posterior drawer test and an active quadriceps drawer test (1+ is 5 mm of
posterior displacement, 2+ is 5-10 mm of displacement, and 3+ is greater than 10 mm of
displacement). Diagnostic imaging includes plain x-rays and MRI scan.

Treatment can be determined as soon as the exact injury has been isolated. Treatment is
controversial in relation to surgical versus nonsurgical management. The use of braces and a
progressive rehabilitation program have been used successfully in athletes with 1+ and 2+
posterior drawer signs. Injuries with a 3+ drawer sign generally require surgery.

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FOOT & ANKLE INJURIES

Injuries in the lower leg, ankle, and foot are quite common in pediatric athletes. The types
of injuries sustained tend to depend on the age group. Young children tend to have
diaphyseal injuries, in contrast to older children in rapid growth, who tend to have
epiphyseal and apophyseal injuries. Perhaps the most common injury evaluated is the ankle
sprain. When a ligament is overloaded tearing can occur. These injuries are graded on a
scale of 1 to 3. A grade 1 injury is a stretch without instability, grade 2 is a partial tear with
some instability, and grade 3 is a total disruption of the ligament with instability of the joint.
The ankle has three lateral ligaments (anterior talofibular, calcaneofibular, and posterior
talofibular) and a medial deltoid ligament. Inversion of the foot generally damages the
anterior talofibular ligament, whereas eversion injures the deltoid ligament. Physical
examination often reveals swelling, bruising, and pain. Tests of ankle stability include the
anterior drawer test (for anterior talofibular stability), the Talar test (of the other lateral
ligaments), and the valgus stress test (of the deltoid ligament). Diagnostic testing includes
x-rays, although in adults criteria determine the timing of radiographs.

Treatment of ankle injuries is imperative to ensure full recovery. Acute injuries should be
iced at least three times per day for up to 20 minutes. Elevation and compression help to
control swelling. Protected weight bearing is allowed in the early phase of rehabilitation. The
second phase begins when the athlete can ambulate without pain. During this time ankle
range of motion is emphasized, along with isometric contractions of the ankle dorsiflexors.
Once 90% of strength has returned, active eccentric and concentric exercises can be added.
The last part of the program is designed to increase strength, improve proprioception, and
add ballistic activity. The "foot alphabet" and "tilt board" are excellent methods to improve
ankle proprioception. This program may take up to 6 weeks before an athlete can return to
full activity. The athlete should wear a protective brace for 3 to 4 months and continue to ice
after exercising.

Plantar fasciitis is common problem that manifests itself as heel pain. It happens in runners
who log more than 30 miles per week and in athletes who have tight Achilles tendons or
poorly fitting shoes. It is common in people with cavus feet and in individuals who are
overweight. The pain is worse upon first standing up in the morning and taking a few steps.
A bone spur is often found on examination. Treatment involves local massage, stretching of
the gastroc-soleus, nonsteroidal anti-inflammatory drugs, arch supports, and local steroid
injections. Runners may need to cut back on their weekly mileage until these measures
eliminate pain.

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PREVENTION
As in all activities most sports-related injuries can be prevented by the use of protective
equipment, common sense, and proper training. Protective equipment should be properly
fitted and maintained by an individual with training and instruction. Helmets should be used
in football, baseball, hockey, bicycling, skiing, in-line skating, skateboarding, or any sport
with risk for head injury. Eye protection should be used in sports that have a high incidence
of eye injuries (eg, basketball, baseball, racquet sports). Proper protective padding should
be identified and used including chest pads for catchers; shin guards in soccer; shoulder,
arm, chest, and leg padding in hockey; and wrist and elbow protectors in skating. A few
common-sense concepts should be addressed by coaches, parents, and physicians in order
to ensure the safety of children participating in sports. These include inspecting playing
fields for potential hazards, adapting rules to the developmental level of the participants,
and matching opponents equally.

The use of the preparticipation history and physical examination can identify potential
problems and allow for prevention and early intervention. Proper training techniques reduce
injuries by encouraging flexibility, promoting endurance, and teaching correct biomechanics.
Sports education reinforces the concepts of fitness and a healthy lifestyle along with sport-
specific training. Early identification of an injury allows the athlete to modify techniques and
avoid micro- and macrotrauma. Once an injury has occurred it needs to be identified
properly and appropriate measures used to minimize inflammation. Rehabilitation of the
injury starts as soon as it has been identified. Early and appropriate care offers the athlete
an optimal chance for full recovery and return to full participation.

Copyright © 2003 by the McGraw-Hill Companies, Inc. All rights reserved.

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