Sports Medicine

ACL Injury

Anterior Cruciate Ligament

ACL is an important soft tissue structure inside the knee joint. It is a thick cord-like structure. Its function is to stabilise the knee joint by connecting between thigh bone (femur) and leg bone (tibia).
ACL is frequently torn by twisting injury to the knee during sports activity and by being hit onto knee from falls.

There are three types of ACL injuries:

• Grade 1. In this type, the ligament is stretched.
• Grade 2. In this type, the ligament is partially torn.
• Grade 3. In this type, the ligament is completely torn.

Symptoms of torn ACL includes popping sensation at the time of injury, pain and swelling of knee, difficulty in moving the injured knee and difficulty in walking. ACL injuries are diagnosed based on the history, examination of the knee and imaging tests (X-ray and MRI)

Managing ACL injuries

A completely torn ACL cannot heal on its own. In athletes and other people of any age who wish to continue doing physically demanding activity, ACL reconstruction surgery is needed. Complete ACL tears are treated through key-hole surgery (Arthroscopy) via small incisions using a combination of fibre optics and small instruments. In ACL reconstruction surgery, the torn ligament is replaced with a tissue graft, which will mimic the natural ACL. A portion of patient’s own tendon (patellar, hamstring, or quadriceps) is used to make a new ACL. A tunnel is drilled into both the tibia and femur. The graft is threaded across the knee and secured in place by using screws, buttons, staples or sutures. This restores the stability to the knee joint. Treatment without surgery may be recommended in older or more sedentary patients.

Partial ACL tears

Partial ACL tears can heal with time. However, some patients with partial ACL tears may still have instability symptoms and needs surgical treatment.

How is this prevented?

• Warm up and stretch before being active.
• Cool down and stretch after being active.
• Give your body time to rest between periods of activity.
• Make sure to use equipment that fits you.
• Be safe and responsible while being active. This will help you avoid falls.
• Maintain physical fitness, including: Strength & Flexibility.

Meniscus Injuries

Meniscus is a pad of fibrocartilage that acts as a cushion within the knee joint. There are two separate meniscus in the knee – one in the inner half of the knee (the medial meniscus) and other in the outer half of the knee (the lateral meniscus). They serve as shock absorbers between the ends of the bones to protect the surface of the articular cartilage. Without a functioning meniscus, the articular cartilage is exposed to increased pressure and tends to wear earlier, leading to osteoarthritis.

Meniscus injury is common, especially among people who play sports. A sudden twist, turn or collision can tear a meniscus. The Main symptom of this condition is the Knee pain, especially at the side of the knee joint.
This condition may be diagnosed based on your symptoms and a physical exam. MRI knee joint helps to confirm the diagnosis.
Acute injuries are managed with Rest, Ice application, medications and physical therapy. If these treatments don’t work or if the injury is severe, surgery might be necessary.

PCL Injury

The posterior cruciate ligament (PCL) is one of the less commonly injured ligaments of the knee. There are far fewer PCL injuries than ACL injuries.

Anatomy

Ligaments are tough bands of tissue that connect the ends of bones together. The PCL is located near the back of the knee joint. It attaches to the back of the femur (thighbone) and the back of the tibia (shinbone) behind the ACL.

The PCL is the primary stabilizer of the knee and the main controller of how far backward the tibia moves under the femur. This motion is called posterior translation of the tibia. If the tibia moves too far back, the PCL can rupture.

Causes

PCL injuries can occur with low-energy and high-energy injuries. The most common way for the PCL alone to be injured is from a direct blow to the front of the knee while the knee is bent. Since the PCL controls how far backward the tibia moves in relation to the femur, if the tibia moves too far, the PCL can rupture.

Sometimes the PCL is injured during an automobile accident. This can happen if a person slides forward during a sudden stop or impact and the knee hits the dashboard just below the kneecap. In this situation, the tibia is forced backward under the femur, injuring the PCL. The same problem can happen if a person falls on a bent knee. Again, the tibia may be forced backward, stressing and possibly tearing the PCL.

Other parts of the knee may be injured when the knee is violently hyperextended, but other ligaments are usually injured or torn before the PCL. This type of injury can happen when the knee is struck from the front when the foot is planted on the ground.

Symptoms

The symptoms following a tear of the PCL can vary. The PCL is not actually enclosed inside the knee joint like the ACL. So unlike an ACL tear, which swells the joint with blood, PCL injuries don't make the knee swell as much. Most patients with a PCL injury sense a feeling of stiffness and some swelling. Some patients may also have a feeling of insecurity and giving way of the knee, especially when trying to change direction on the knee. The knee may feel like it wants to slip.

Diagnosis

The history and physical examination is probably the most important tool in diagnosing a ruptured or deficient PCL. During the physical examination, special stress tests are performed on the knee. The magnetic resonance imaging (MRI) scan is more accurate test.

Treatment

Initial treatment for a PCL injury focuses on decreasing pain and swelling in the knee. Rest and mild pain medications help decrease these symptoms. You may need to use a long-leg brace and crutches at first to limit pain.

Less severe PCL tears are usually treated with a progressive rehabilitation program. If the PCL alone is injured, nonsurgical treatment may be all that is necessary. When other structures in the knee are injured, patients generally do better having surgery within a few weeks after the injury. Long-term studies show that without reconstructive surgery, over time, knee instability and joint degeneration develop.

Multi ligament injury

The 4 ligaments in and around the knee which are the main reasons for the stability are ACL, PCL, MCL and LCL - (ACL- Anterior Cruciate ligament, PCL- Posterior Cruciate Ligament, MCL- Medial collateral ligament, LCL- Lateral collateral Ligament). Normal tension within the ligament prevents abnormal movements within the knee joint When two or more major ligaments of the knee are injured, it is termed as multi-ligamentous injury.

Such type of injury occurs as result of high velocity trauma like Road Traffic Accidents. X-rays of the knee are done to rule out fractures and to check the knee alignment/ knee dislocation.
MRI of the knee is done to assess the number of the ligaments that have been damaged & also other associated injuries like meniscus/cartilage injuries. Treatment for multi-ligament injury is always surgical reconstruction.

Articular Cartilage lesions

An articular cartilage injury is damage to the cartilage that lines the surface of joints (articular cartilage). The cartilage is smooth, white tissue that covers the ends of bones where they meet at a joint. This cartilage allows smooth movement of the joint. It also acts as a thin cushion between the bones of the joint. Injuries to joint cartilage can cause pain and decrease range of movement.

Articular cartilage damage can occur from a recent (acute) injury or from wear and tear that takes place over time. The knee joint is the most common area for this type of injury.

What are the causes?

This injury may be caused by:

• A fall.
• A hard, direct hit to the joint.
• Long-term wear and tear of a joint.
• Other injuries, such as: Joint fracture or dislocation, A tear of joint cartilage.

Symptoms of this condition include:

• Pain and swelling in the joint.
• Giving way or locking of the joint.
• Stiffness and decreased range of motion of the joint.
• A crackling or clicking sound within the joint when it moves

This condition may be diagnosed based on your symptoms, your history of injury, and a physical exam. You may also have tests, such as:

• MRI.
• A procedure in which a thin scope is used to check inside the joint (arthroscopy).
• X-rays may show a defect in the bone due to damage to cartilage and are used to help rule out other conditions that may be similar to an articular cartilage injury.

Treatment depends on the severity of the injury and the joint that is involved. Treatment options include:

• Resting the joint.
• Icing the joint.
• Medicines that reduce swelling and pain (NSAIDs).
• Injecting a steroid medicine into the joint.
• Wearing a splint, brace, or sling.
• Physical therapy.
• Surgery. This may involve any of the following:
  • Drilling holes through the cartilage into the bone underneath it to improve blood flow.
  • Removing torn or damaged cartilage.
  • Replacing cartilage with a type of cartilage graft.
  • Replacing the entire joint.

Patellar Instability

The kneecap (patella) is located in a groove in front of the lower end of the thighbone (femur). This groove is called the patellofemoral groove. A patellar dislocation occurs when your patella slips all the way out of the groove.

This condition may be caused by:

• Sports injuries.
• Twisting the knee when the foot is planted.

The patellar dislocation results in the rupture of a ligament on the inner side of the knee called the MPFL(medial patellofemoral ligament) that keeps the kneecap in center of knee. Deficient MPFL can lead to recurrence of the dislocation even with trivial trauma. Less common factors such as altered limb alignment, flattening of the grove underlying the patella(trochlea dysplasia), Patella alta (relatively higher position of the patella) can also cause recurrence.

MRI scan with or without CT are essential for assessing the abnormalities in recurrent patella dislocation.
In general, the initial treatment of most patellar dislocations is nonoperative with a dedicated rehabilitation program.
In those patients who have recurrent dislocations, the recommended treatment is surgery to stabilise the knee to the center of knee.

Rotator cuff tear

Tendons are cord-like bands that connect the muscle to the bone. Rotator cuff is a group of 4 muscles and tendons that surround the shoulder joint and keep the head of the humerus (upper arm bone) in the shoulder socket.

Rotator cuff tear refers to the partial or complete rupture in one or many of the rotator cuff muscle group (Supraspinatus, Infraspinatus, Subscapularis, Teres Minor) The tear can occur suddenly (acute tear) or can develop over a long period of time (chronic tear).

Acute tears may be caused by:

• A fall, especially on an outstretched arm.
• Lifting very heavy objects with a jerking motion.

Chronic tears may be caused by overuse of the muscles. This may happen in sports, physical work, or activities in which your arm repeatedly moves over your head. Most tears are the result of a wearing down of the tendon that occurs slowly over time.

Symptoms of this condition depend on the type and severity of the injury:

• An acute tear may include a sudden tearing feeling, followed by severe pain that goes from your upper shoulder, down your arm, and toward your elbow.
• A chronic tear includes a gradual weakness and decreased shoulder motion as the pain gets worse. The pain is usually worse at night.
• This condition is diagnosed with your medical history and physical examination. Imaging tests may also be done, including: X-rays and MRI.
• Treatment for this condition depends on the type and severity of the condition. In less severe cases, treatment may include: Rest with a sling immobilisation, Activity restriction, Icing the shoulder, Anti-inflammatory medicines.
• Strengthening and stretching exercises.
• In more severe cases and if the pain does not improve with non-surgical methods, surgery is required.

Shoulder Instability

Shoulder dislocation occurs when the head of the upper arm bone is forced out of the shoulder socket. This typically happens as a result of a sudden injury, such as a fall or accident. Once a shoulder has dislocated, it is vulnerable to repeat episodes. When the shoulder is loose and slips out of place repeatedly, it is called as Recurrent shoulder dislocation or instability. Instability results from the tear in the rim of cartilage (labrum) around the edge of the shoulder socket (glenoid). In some cases, bone loss happens at the ball (humeral head) and/or the socket (glenoid)

Common symptoms are:

• Repeated instances of the shoulder giving out
• A persistent sensation of the shoulder feeling loose, slipping in and out of the joint
• Pain in the shoulder

Diagnosis is arrived by physical examination. X ray, MRI with or without CT scan is used to assess the tear in the labrum and bony defects resulting from repeated episodes of dislocation. First time shoulder dislocation is often first treated with nonsurgical options. Recurrent shoulder instability always need surgical treatment.

Frozen shoulder

Frozen shoulder, also called adhesive capsulitis, causes pain and stiffness in the shoulder. Over time, the shoulder becomes very hard to move.
Frozen shoulder most commonly affects people between the ages of 40 and 60, and occurs in women more often than men. In addition, people with diabetes are at an increased risk for developing frozen shoulder.
Normal shoulder joint is capable of moving in all directions. Adhesive capsulitis is when you lose the ability to move your shoulder around in all directions. The shoulder capsule thickens and becomes stiff and tight.

Symptoms include:

• Pain over the outer shoulder area, which is usually dull.
• Decreased Range of motion of shoulder joint which leads to difficulty in taking the arms overhead, raising the arms out to the sides of the body, difficulty reaching behind the back or back of the head.

Your doctor may be able to tell you have adhesive capsulitis just by talking to you about your symptoms and examining your shoulder. Your doctor may also want to take an X-ray or do a magnetic resonance imaging (MRI) scan of your shoulder to look for other problems.

Treatment

Frozen shoulder generally gets better over time, although it may take few months. The focus of treatment is to control pain and restore motion and strength through physical therapy. Pain medications helps to reduce the pain and relax the muscles. Using a heating pad or ice pack may help to reduce the pain.

Surgical Treatment

If your symptoms are not relieved by therapy and other conservative methods, surgical treatment might be recommended.

Shoulder Impingement Tendinitis

Shoulder joint pain commonly results from the following:

• Tendinitis. The rotator cuff tendons can be irritated or damaged.
• Bursitis. The bursa can become inflamed and swell with more fluid causing pain.
• Impingement. When you raise your arm above the shoulder level, the space between the acromion and rotator cuff narrows. The acromion can rub against (or impinge on) the tendon and the bursa, causing irritation and pain.

Those who do repetitive lifting or overhead activities using the arm are prone to develop this condition.
At first, symptoms may be mild. As the problem progresses, the symptoms increase:

• Pain at night
• Loss of strength and motion
• Difficulty doing activities that place the arm behind the back, such as buttoning or zipping clothing.

The diagnosis is arrived through physical examination, x rays and MRI. In most cases, initial treatment is nonsurgical. Many patients experience a gradual improvement and return to function.
When nonsurgical treatment does not relieve pain, surgery is recommended.

AC Joint disruption

The AC joint is where the collarbone (clavicle) meets the highest point of the shoulder blade (acromion). When this joint gets disrupted, collar bone separates from the shoulder blade, creating a bump on the top the shoulder.

The most common cause for a separation of the AC joint is from a fall directly onto the shoulder. The injury is easy to identify when it causes deformity.
When there is less deformity, the location of pain and X-rays help to make the diagnosis. Nonsurgical treatments, such as a sling and medications can effectively help manage the pain in almost all patients. Most people with this injury return to normal function with nonsurgical treatments.
Surgery can be considered if pain persists or the deformity is severe.

Biceps tendonitis

Biceps tendonitis is the inflammation in the tendon that attaches the top of the biceps muscle to the shoulder. The most common cause is overuse from certain types of work or sports activities. It can also happen suddenly from a direct injury.

Patients generally report the feeling of a deep ache directly in the front and top of the shoulder. The ache may spread down into the main part of the biceps muscle. Pain is usually made worse with overhead activities.
Treatment typically involves a period of rest and avoidance of activities that aggravate the pain. Most patients recover with medicines and physiotherapy. Some injuries require surgery for treatment.

SLAP tears

A SLAP lesion (superior labrum, anterior [front] to posterior [back]) is a tear of the labrum (a rim of cartilage) that occurs on the upper part of the shoulder joint socket (glenoid) It may also involve the origin, or starting point, of the long head of the biceps tendon. Injuries to the tissue rim surrounding the shoulder socket can occur from acute injury like fall or repetitive shoulder overuse.

Symptoms of this condition include:

• Pain, usually with overhead activities. Occasional night pains.
• Locking or popping sensation
• Decreased range of motion
• Loss of strength

MRI scan of the shoulder is required to diagnose this condition.
In many cases, nonsurgical methods are effective in relieving symptoms and healing the injured structures. If these nonsurgical measures are insufficient, or if the symptoms return, Surgery is recommended.