Orthopedics

Sports Medicine & Rehabilitation

Sports Medicine

SHOULDER

Shoulder problems including pain, are one of the more common reasons for physician visits for musculoskeletal symptoms. The shoulder is the most movable joint in the body. However, it is an unstable joint because of the range of motion allowed. This instability increases the likelihood of joint injury, often leading to a degenerative process in which tissues break down and no longer function well.

SLAP lesion:

A SLAP (superior labrum anterior to posterior) tear occurs when a special type of tissue called labral tissue of the shoulder gets torn from the glenoid (socket) bone. This causes pain in the shoulder, typically in overhead movements
It can occur due to fall on an outstretched hand or as an overuse injury in overhead throwing sports (cricket, volley ball etc.)
When physiotherapy fails to improve the condition , an arthroscopic surgery can be performed to reattach the torn labrum
Treatment also comprises of specific exercises

Rotator cuff tears:

The term "rotator cuff" refers to a group of four tendons that blend together as they attach to the upper end of the arm bone (humerus). Normally these tendons transmit the force of muscles originating on the shoulder blade (scapula) to the arm providing motion and stability
Defects in the rotator cuff can come from a sudden injury (cuff tear) or from degeneration (wear and tear in older people). But in sports , rotator cuff may get damaged due to overuse of the shoulder
The symptoms of rotator cuff disease include difficulty lifting the arm and pain while lifting the arm
Smaller tears can be improved with physiotherapy but more significant tears require surgery to repair the torn tissue, usually arthroscopic surgery in this case

Dislocation:

The shoulder joint is the most frequently dislocated major joint of the body. In a typical case of a dislocated shoulder, a strong force that pulls the shoulder outward or extreme rotation of the joint pops the ball of the shoulder out of the shoulder socket
The shoulder can dislocate either forward, backward, or downward but most frequently in forward direction. Not only the arm appears out of position when the shoulder dislocates, but the dislocation also produces severe pain. Muscle spasms may increase the intensity of pain
Dislocation is treated by putting the head of the humerus (ball) back into the joint socket — a procedure called Manipulation & Reduction (M&R). The arm is then immobilized in a sling or a device called a shoulder immobilizer for several days
In some patients, the shoulder keeps dislocating repeatedly. This condition is called recurrent dislocation. Treatment of this troublesome problem requires surgery to prevent the dislocation from happening again and again. Majority of these patients can be cured by an arthroscopic type (Key-hole / Endoscopic) of surgery

Impingement Syndrome:

Shoulder impingement syndrome, also called painful arc syndrome, supraspinatus syndrome, swimmer's shoulder, and thrower's shoulder, is a clinical syndrome which occurs when the tendons of the rotator cuff muscles become irritated and inflamed as they pass through the subacromial space, the passage beneath the acromion.
The most common symptoms in impingement syndrome are pain, weakness and a loss of movement at the affected shoulder. The pain is often worsened by shoulder overhead movement and may occur at night, especially if the patient is lying on the affected shoulder.
Impingement syndrome is usually treated conservatively which may include rest, cessation of painful activity, and physiotherapy focused at maintaining a range of movement and avoids shoulder stiffness
A local steroid injection may be helpful
Rarely an arthroscopic surgery may be necessary

ELBOW

Tennis elbow:

Lateral epicondylitis or lateral epicondylalgia, also known as tennis elbow, shooter's elbow and archer's elbow, is a condition where the outer part of the elbow becomes sore and tender. Even though it is common in tennis players, it may occur to sportsmen playing any sport. Tennis elbow is an overuse injury occurring in the lateral side of the elbow region, but more specifically, occurs at common extensor tendon that originates from the lateral epicondyle
The symptoms may include pain on the outer part of elbow, point tenderness over the lateral epicondyle – a prominent part of the bone on the outside of the elbow, gripping and movements of the wrist hurt, especially wrist extension and lifting movements
Conservative treatment includes Non-steroidal Anti-inflammatory Drugs (NSAIDs) to relieve lateral elbow pain in the short term and physiotherapy including stretches and progressive strengthening exercises to prevent re-irritation of the tendon and other exercise measures. A counter-force brace or "elbow strap" is used to reduce strain at the elbow epicondyle, and to limit pain provocation and offer protection against further damage
In recalcitrant cases, surgery may be an option. Either arthroscopic surgery or an open surgery can be done
Return to sport requires corrections in the technique of the game and adjustment of the racquet / bat etc. which might have predisposed for the condition

Golfer’s elbow:

Golfer's elbow or medial epicondylitis is an inflammatory condition of the medial epicondyle of the elbow. It is in some ways similar to tennis elbow. The tendons of anterior forearm muscles come together in a common tendinous sheath, which is inserted into the medial epicondyle of the humerus at the elbow joint. In response to minor injury, or sometimes for no obvious reason at all, this point of insertion becomes inflamed.
Non-specific palliative treatments include: Non-steroidal Anti-inflammatory Drugs (NSAIDs). A counter-force brace or "elbow strap" is used to reduce strain at the elbow epicondyle, and to limit pain provocation offer protection against further damage. Physiotherapy will include a variety of exercises for muscle/tendon reconditioning, starting with stretching and gradual strengthening of the flexor-pronator muscles
If all else fails, debridement of the damaged muscle (a surgery) may be effective

Little League Elbow

Little League Elbow (LLE) syndrome is a valgus overload or overstress injury to the medial elbow that occurs as a result of repetitive throwing motions. It is most commonly seen in children and adolescents playing sports like tennis, javeline throw, baseball etc.
Signs and Symptoms include pain on the inner side of the elbow, decreased throwing speed or distance, point tenderness, swelling, deformity (flexion contracture)
Conservative treatment commonly consists of complete rest from throwing activities for a minimum of 4-6 wks, ice, Non-steroidal Anti-inflammatory Medication (NSAIDs), elbow extension brace if a flexion contracture is present, immobilization if symptoms are severe and physiotherapy to correct abnormal biomechanics
Arthroscopic surgery may be necessary to treat loose bodies in the joint and cartilage injuries etc.

WRIST AND HAND

There are a number of bones in the wrist joint which can sustain fractures or the ligaments connecting various bones can be injured

Scapholunate Ligament Injury

Can happen due to fall on the palm with dorsiflexed wrist;
When arthroscopy is indicated, simple cleaning of the ligament is sufficient in case of minor injuries and ligament repair is advised in case of severe injuries

Lunotriquetral Ligament Injury

Pain on the inner side of wrist
Happens due to fall on the palm thus affecting the radiotriquetral attachments
Conservative management with wrist immobilization is advised
Arthroscopic surgery or sometimes open surgery may be required

Mallet finger

It is an injury of the extensor digitorum tendon of the fingers at the last joint of the finger
It usually occurs when a ball (such as a softball, basketball, or volleyball), while being caught, hits and suddenly bends a finger
Symptoms include pain and a bent finger with an inability to straighten the finger
Treatment options include putting the finger in a Mallet splint. The splint allows the tendon to return to normal length. If the finger is bent during these weeks the healing process must begin all over again. Occasionally surgery is used to reattach the tendon

HIP

Snapping Hip Syndrome

Snapping Hip Syndrome (also referred to as coxa saltans, iliopsoas tendinitis, or dancer's hip) is a medical condition characterized by a snapping sensation felt when the hip is flexed and extended
Symptoms include an audible snapping or popping noise and pain or discomfort. Pain often decreases with rest and diminished activity. Without proper treatment symptoms usually last months or years, and can be very painful
If it is painless, there is little cause for concern. This condition is usually curable with appropriate treatment, or sometimes it heals spontaneously. Correcting any contributing biomechanical abnormalities and stretching tightened muscles, such as the iliopsoas muscle or iliotibial band is the goal of treatment to prevent recurrence
Corticosteroid injections may be used for pain relief. Surgery may be recommended if the patient does not respond well to medicine or physical therapy, or if abnormal structures are found

Greater Trochanteric Pain Syndrome

Greater Trochanteric Pain Syndrome (GTPS), also known as trochanteric bursitis, is inflammation of the trochanteric bursa, a part of the hip
The symptoms are pain in the hip region upon walking, and tenderness over the upper part of the femur, which may result in the inability to lie in comfort on the affected side
The primary treatment advised is rest and avoiding actions which result in aggravation of the pain. Icing the joint may help. Non-steroidal Anti-inflammatory drugs may relieve pain and reduce the inflammation
Physical therapy to strengthen the hip muscles and stretch the iliotibial band can relieve tension in the hip and reduce friction. The use of ultrasound may also be helpful
The inflamed bursa can be removed surgically through a procedure known as Bursectomy

Strain

A strain is an injury to a muscle or tendon in which the muscle fibres tear as a result of overstretching. A strain is also colloquially known as a pulled muscle. The equivalent injury to a ligament is a sprain. Strains are commonly seen in hamstrings, quadriceps and adductors (groin pull)
Typical symptoms of a strain include: localized pain, stiffness, discoloration and bruising around the strained muscle
Commonest strains are adductor strain in which the player complains of pain on the inner side of the thigh which are commonly seen in sportsmen who play sports like hockey, football etc. In hamstring strain, the player complains of sudden onset of pain in the back of the thigh, commonly seen in sprint events and water skiing. In Quadriceps strain, the player complains of pain in the front of the thigh, common in sports involving kicking movements like soccer
The first-line treatment for a muscular strain in the acute phase include four steps commonly known as R.I.C.E [Rest ,Ice, Compression & Elevation]
This immediate treatment is usually accompanied by the use of Nonsteroidal Anti-inflammatory Drugs. Therapeutic ultrasound can be used to break down poorly healed muscle strains and permit them to heal properly

Femoroacetabular Impingement

Femoroacetabular Impingement (FAI) or hip impingement syndrome is a condition affecting the hip joint in young and middle-aged adults. Impingement occurs when the ball shaped femoral head rubs abnormally or doesn't have full range of motion in the acetabular socket. Damage in the hip joint can occur to the articular cartilage or the labral cartilage
FAI-related pain may be felt in the groin, lower back and generally around the hip
Conservative/nonsurgical treatments include reducing levels of physical activity and taking pain medication and physiotherapy sessions. Surgical intervention may include an arthroscopic or open surgery

KNEE

Anterior Cruciate Ligament (ACL) injury

An injury to the anterior cruciate ligament can be a debilitating musculoskeletal injury to the knee, seen most often in athletes.
Symptoms of an ACL injury include hearing a sudden popping sound, swelling, and instability of the knee. Pain is also a major symptom in an ACL injury and can range from moderate to severe. In a chronic ACL injury the commonest complaint is one of an unstable knee with feeling of frequent slipping of the knee especially with sporting activities, running and jumping etc. Continued athletic activity on a knee with an ACL injury can have devastating consequences, resulting in massive cartilage damage, leading to an increased risk of developing osteoarthritis later in life
A partial tear can be conservatively managed with physiotherapy and use of a knee brace
Surgery involves an arthroscopic surgery to reconstruct the torn ACL ligament. ACL surgery is one of the commonest sports surgeries carried out these days. It commonly involves reconstruction with a hamstring muscle graft. ACL surgery over the decades has evolved and recent advances like the anatomic ACL reconstruction and double bundle ACL reconstruction are being increasingly used

Posterior Cruciate Ligament Injury

The incidence of injuries of the PCL is less than that of the ACL. This might be due to greater thickness of the PCL.
Symptoms of a PCL tear can vary; the most obvious include pain, swelling and a feeling of unsteadiness in the knee
A partial tear can be conservatively managed with physiotherapy and use of a knee brace
Whereas in a complete tear, a procedure called PCL reconstruction can be done by an arthroscopic surgery with a hamstring muscle graft

Posterolateral Corner Injury

The Posterolateral Corner (PLC) of the knee is a complex area of the knee on the outer side formed by the interaction of multiple structures. Injuries to the Posterolateral Corner can be debilitating to patients and require prompt recognition and treatment to avoid long term consequences
Injuries to the PLC often occur in combination with other ligamentous injuries to the knee; most commonly the Anterior Cruciate Ligament (ACL) and Posterior Cruciate Ligament (PCL)
Patients often complain of pain and instability at the joint. With concurrent nerve injuries, patients may experience numbness, tingling and weakness of the ankle dorsiflexors and great toe extensors
Conservative treatment relies on immobilizing the knee to allow the stretched or torn ligaments to heal. Surgical treatment involves reconstruction of PLC with a muscle graft

Meniscal Tear

A tear of a meniscus is a rupturing of one or more of the fibrocartilage strips in the knee called menisci
They can be torn by traumatic force encountered in sports or other forms of physical exertion. The traumatic action is most often a twisting movement at the knee while the leg is bent. In older adults, the meniscus can be damaged following prolonged 'wear and tear' called a degenerative tear
The patient's primary complaints are usually knee pain and swelling. These worsen when the knee bears more weight (for example, while running). Another typical complaint is joint locking
Conservative management involves physical therapy which involves exercise to strengthen the muscles around the knee. The patient will probably have to take a small break from his or her normal activities, allowing the knee to heal
Surgical procedure involves arthroscopic surgery of the knee depending on the type of the tear. The torn portion can be excised (partial meniscectomy) or the tear can be repaired (meniscal repair)

Patellar Tendinitis

Patellar Tendinitis (Patellar Tendinopathy, also known as jumper's knee and Sinding-Larsen-Johansson disease), is a relatively common cause of pain in the inferior patellar region in athletes. It is common with frequent jumping.
Patients report anterior knee pain, often with an aching quality. The symptom onset is insidious. It begins as inflammation in the patellar tendon where it attaches to the patella and may progress by tearing or degenerating the tendon
Early stages may be treated conservatively using the R.I.C.E (Rest, Ice, Compression and Elevation) methods. A physical therapist may also recommend specific exercises and stretches to strengthen the muscles and tendons
Uncommonly it may require surgery to remove myxoid degeneration in the tendon

Patellofemoral Pain Syndrome

Patellofemoral Pain Syndrome (PFPS) is a syndrome characterized by pain or discomfort seemingly originating from the contact of the posterior surface of the patella (back of the kneecap) with the femur (thigh bone). It is the most frequently encountered diagnosis in sports medicine clinics
Typically patients will complain of pain in the front of the knee which is exacerbated by sports, walking, sitting for a long time, or stair climbing. Descending stairs may be worse than ascending
VMO strengthening is commonly suggested because it helps to stabilize the patella. Inflexibility has often been cited as a source of patellofemoral pain syndrome. Stretching of the hip, hamstring, calf and iliotibial band may help restore proper biomechanics
In addition to physical therapy, external devices such as braces and tape could be used to stabilize the knee. Arch supports and custom orthotics may also help to improve lower extremity biomechanics
Patellar Tendon Rupture is a rupture of the tendon that connects the patella to the tibia. When rupture occurs, the patella loses support from the tibia and moves toward the hip where the quadriceps muscle contract, hindering the leg's ability to extend. This means that those affected cannot stand, as their knee buckles and gives way when they attempt to
If the tendon rupture is partial, then non-surgical methods of treatment may suffice. Complete rupture requires surgical procedure where the tendon is repaired onto the patella. In some cases muscle graft may be necessary.

ANKLE AND FOOT

Ankle Sprain

Ankle Sprain also known as a sprained ankle, twisted ankle, rolled ankle, ankle injury or ankle ligament injury, is a common medical condition where one or more of the ligaments of the ankle is torn or partially torn.
Types of sprains:
- Inversion (lateral) Ankle Sprain: The most common type of ankle sprain occurs when the foot is inverted too much, affecting the lateral side of the foot. When this type of ankle sprain happens, the ligament on the outer side of the ankle is either stretched or torn. Approximately 90% of ankle sprains belong to this category
- Eversion (medial) Ankle Sprain: A less common type of ankle sprain is called an eversion injury, affecting the medial side of the foot. When this occurs, the ligament on the inner side of the ankle (deltoid ligament) is injured
Pain, swelling, warmth and redness are the common symptoms
Use of a proper compression wrap is the most important first step. Use of Rest, Ice, Compression and Elevation method of conservative management is to be followed
When the problem persists for a prolonged time arthroscopic or open surgery can be carried out to repair the ligaments

Achilles Tendinopathy

Achilles tendon is the prominent tendon on the back of the calf going to the back of the heel
Achilles Tendonitis (also Achilles tendinopathy) is tendonitis of the Achilles tendon, generally caused by overuse and is more common among athletes training in under less than ideal conditions
Pain, tenderness, swelling, warmth are the common symptoms found
Treatment is possible with ice, cold compression therapy, wearing heel pads to reduce the strain on the tendon, and an exercise routine designed to strengthen the tendon
Conservative management may also include Non-steroidal Anti-inflammatory drugs, ultrasound therapy and physical therapy techniques.

Flat Foot:

Flat Feet (also called pes planus or fallen arches) is a formal reference to a medical condition in which the arch of the foot collapses, with the entire sole of the foot coming into complete or near-complete contact with the ground.
Although many people have no signs or symptoms associated with flat feet, some people experience foot pain, particularly in the heel or arch area, difficulty standing on tiptoe, swelling along the inside of the ankle. These patients are more prone for repeated ankle sprains with sports
Shoe inserts (orthotic devices) may help relieve the pain caused by flat feet. Shoe inserts won't cure flat feet, but they often reduce the symptoms associated with the disorder. Some people with flat feet also have a shortened Achilles tendon. Exercises to stretch this tendon may help.
In some cases, surgery can provide lasting relief, and even create an arch where non existed before. However it should be considered as a last resort.

Stress fracture

A Stress Fracture is a type of incomplete fracture in bones. It is caused by "unusual or repeated stress" and impact of heavy weights on the ankle or leg
It typically occurs in weight-bearing bones, such as the tibia (bone of the lower leg) and metatarsals (bones of the foot). It is a common sports injury, and most cases are associated with athletics
Stress fractures usually have only a few symptoms. A stress fracture could be present as a generalized area of pain and tenderness associated with weight bearing
If a stress fracture occurs in a weight-bearing bone, healing will be delayed or prevented by continuing to put weight on that limb. Rest is the good option for complete healing of a stress fracture.
With severe stress fractures, surgery may be needed for proper healing.