Student Pages

INTRODUCTION TO SPORTS PODIATRY

A) Outline

B) Overview

C) Pattern of injury

A) OUTLINE:

Sports Lectures

Session 1: Introduction to sports podiatry, Aetiology of sports injuries

Session 2: Overview of sports footwear

Session 3: Treatment, rehabilitation and preventative management

Session 4: Midfoot and forefoot sports injuries

Session 5: Ankle and rearfoot sports injuries

Session 6: Sports injuries of the knee/exercise induced leg pain

Session 7: Sports footwear seminars

Sports Texts

Brukner & Khan 2nd Edition “Clinical Sports Medicine” 2001 McGraw Hill

Subotnik “Sports Medicine of the Lower Extremity” 2000 Churchill Livingstone

Delee & Drez “Orthopaedic Sports Assessment” volumes 1-3, 1995 Williams & Wilkins

O'Connor & Wilder “Textbook of running medicine” 2001 McGraw Hill

Nicholas & Hershman “The lower extremity & spine” volumes 1-2, 1995 Mosby

Sports Journals

American Journal of Sports Medicine

British Journal of Sports Medicine

Medicine & Science in Sports & Exercise

International Journal of Sports Medicine

Clinical Sports Medicine

Journal of Orthopaedic & Sports Physical Therapy

The Physician and Sportsmedicine

Sports Medicine

B) OVERVIEW

Learning Objectives

Have a detailed understanding of the role of a podiatrist treating sports injuries

Have an appreciation of the differences between working in a multi/interdisciplinary sports

medicine team or as a sole practitioner

What is a sports injury?

What Is A Sports Podiatrist?

What Do You Need?

Sporting Statistics

<60% of all injuries occur below the hip

Commonest acute injury is ankle sprain (Garrick, 1977; Safron et al. 1999)

Commonest tendon injury is to the Achilles (Marks, 1999; Anderson & Hall, 1997)

Commonest joint pathology is patellofemoral (Brukner & Khan, 1993; McConnell, 1986)

What Should a Sports Podiatrist Do?

Making the Diagnosis

Thorough history

Know your anatomy

Appropriate test selection

Specialist investigations

Multidisciplinary Team

Patient Advice

Mechanical Treatment

Physical Treatment

Pharmacological Treatment

Knowledge Base

Sports injuries

Assessment techniques

Know the sport

Sporting technique

Footwear

Treatment options

Referral options

C) PATTERN OF INJURY

Learning objectives

Have a detailed understanding of the differences between acute and chronic injuries

The injuries that can occur to tissues of the body during sport

Sports injuries

  Acute

  Chronic

Acute injuries:

Bone

Fractures

          Direct or indirect trauma

Closed or open

          Classifications

transverse, oblique, spiral, comminuted, avulsion

          Features

Pain, tenderness, bruising, oedema ± deformity, motion restriction

          Treatment

Non-displaced: bracing and casting

Displaced: reduction and immobilisation ± surgical stabilisation

Thordarson D (1996). Detecting and treating common foot and ankle fractures: Part 1:

The ankle and hindfoot. The Physician and Sports Medicine; 24(9); September

Thordarson D (1996). Detecting and treating common foot and ankle fractures: Part 2:

The midfoot and forefoot. The Physician and Sports Medicine; 24(10); October

ePodiatry's resources on fractures

Periosteal contusion

A bruise caused by a blow to the periosteum; caused when blood pools around the

injury. Usually from direct blow.

                     Treatment?

Articular cartilage

Shearing or blunt trauma

            Three classes of injuries:

Disruption of

1. deep articular cartilage

2. articular cartilage surface

3. articular cartilage and bone (osteochondral defect/#)

Joint injury

Subluxation/dislocation

            Complete versus partial dissociation

            Damage capsule and ligaments

            Treatment

 X-ray, protected mobilisation and muscle strengthening, ± surgery

Ligament sprain/tear

            Grade I

            Grade II

            Grade III

            Dy/dx avulsion #

            Management ligament tears

Muscle

Strain/tear

          Occur at a critical tension, frequently associated with eccentric contractions

Two-joint muscles (gastrocnemius) more susceptible?

      Grade I 

      Grade II

      Grade III

      Management

RICE, NSAIDs then massage, stretching, electrotherapeutic modalities and

strengthening

Contusions (‘corky')

          Direct trauma common in impact sports

          Tenderness, diffuse swelling/haematoma, reduced motion and strength

          Considered ‘minor'

      Management

Initially: RICE..immobilise (quadriceps) under stretch for faster repair…avoid heat,

alcohol and massage

Later: gentle mobilisation, massage and stretching to resorb clot

Full recovery ~14 days

Myositis Ossicans

Haematoma calcification, Suspect in delayed recovery, Dx via X-ray

Larson et al (2002) Evaluating and managing muscle contusions and

myositis ossificans. The Physician and sports medicine; 30(2)

Cramps

Schwellnus M (1999). Skeletal muscle cramps during exercise. The Physician

and Sports Medicine; 27(12); November

Painful involuntary muscle contractions:

At exercise, rest or sleep

Commonly in calf muscles

Aetiology?

Management

Tx aetiological factors, Quinine sulfate

Tendon

Complete/partial rupture

Occur at least vascular site or at musculoskeletal junction

Achilles is common (2cm above insertion), peroneals

following inversion sprains

Sudden onset of pain with localised tenderness

Difficult to distinguish tendinopathy

Dx: US, MRI if indicated

Mx: Surgery with rehabilitation

Chronic injuries:

Bone

Stress reaction/fracture

Brukner et al (1998). Managing stress fractures:

Let risk level guide treatment. The Physician and

Sports Medicine; 26(8) August

‘Microfracture in bone resulting from repetitive physical loading below the single

cycle threshold'

Stress fractures account for between 0.7% and 15.6% of all injuries sustained

by athletes (Brukner, Bennell and Matheson, 1999)

Specific sites associated with specific activities

Usually in lower limb

Tibia (45%), Fibula (12%), Metatarsal (8%),

Navicular (15%), Femur (8%) and

Pelvis (4%) (Bennell et al., 1996)

Stress fracture pathophysiology

Bone remodels when cyclically loaded

Five stages of remodelling

1. Quiscence

2. Activation

3. Resorption

4. Reversal

5. Formation

Repetitive loading during the reversal phase can lead to micro

damage (stress reaction) and eventually fracture (stress fracture)

Diagnosis

Hx of recent increase in load

                     Symptoms & Signs

Imaging:

X-rays: poor sensitivity, no changes for at least 3 weeks – periosteal bone formation,

sclerosis or fracture line

Bone Scans (Triple phase technetium-99m bone scan): highly sensitive but poor

specificity

CT/MRI: for exact site and extent of fracture

Management

Uncomplicated fractures

High risk fractures

Prone to delayed or non-union

Need non-weight bearing cast immobilisation ± surgery

High risk stress fractures

Osteitis/periostitis/tenoperiostitis

Inflammation of bone/periosteum/tendon-periosteum

Medial border tibia (soleus attachment) common with tenderness

:

Treatment

RICE

massage, reducing stress on periosteum

Apophysitis

Inflammation of an apophysis (growth plate for the insertion of

muscle-tendon

within a developing bone

DiFiori JP (1999). Overuse Injuries in Children and Adolescents.

The Physician and Sports Medicine; 27(1) January.

Articular Cartilage

Chondromalacia

        Softening, fibrillation, fissuring and ultimately gross degenerative changes of the articular

        cartilage of the patella

        Patellofemoral syndrome

Ligament
        Overuse injuries rare

Muscle
Chronic compartment syndrome
              Increased interstitial pressure within an anatomically confined muscle compartment

              Symptoms:

              Dx: must exercise to reproduce symptoms, possible fascial defect, intra-compartmental

              pressure testing
              Tx: massage, biomechanical correction, activity modification, fasciotomy/fasciectomy

Delayed onset muscular soreness
              Dull ache developing 24-48 hours after unaccustomed exercise or new activity (eccentric

              muscle activity)

              Aetiology unclear
                  torn tissue…
                  Focal tissue thickening/fibrosis
                  Interfibril muscle adhesions with fascial cross-linkages
                  Firm focal areas to large areas of thickening
                  Local pain or affect elasticity of tendons

Tendon
Tendinopathy/Tendinosis
Khan K et al (2000). Overuse Tendinosis, Not Tendinitis Part 1: A New Paradigm for a Difficult

Clinical Problem. The Physician and sports medicine; 28(5): May

Loss of collagen continuity, increase in ground substance, vascularity and cellularity (fibroblasts

NOT inflammatory cells)

Due to aging, microtrauma or vascular compromise
Recovers 6-10 weeks (early Dx) to 3-6 months (late Dx)

Tx:




Bursae
Bursitis
       Bursae facilitate movement of tendons over bones
                May become irritated from overuse
                           inflammation
                           pain with movement
                           restriction of movement
                           tenderness to touch
                           pain with stretching
                          dramatic immediate swelling
                          Warmth

Tx: RICE, NSAIDs, corticosteroids, drainage

Summary
   Difference between acute and chronic injuries
   Have an appreciation of the Dx and Mx of injuries to
   Bone
   Cartilage
   Joints
   Ligaments
   Muscles
   Tendons
   Bursae
   Nerves and skin

Aetiology of sports injuries

References
Brukner et al. (1999). Epidemiology of stress fractures. Stress Fractures; Chapter 2, pp.15-41

Murphy et al. (2003). Risk factors for lower extremity injury: a review of the literature. Br J Sports Med; 37: 13-29 (http://bjsm.bmjjournals.com/cgi/content/full/37/1/13)

Neely FG (1998). Intrinsic risk factors for exercise-related lower limb injuries. Sports Med; 26(4): 253-263

Neely FG (1998). Biomechanical risk factors for exercise-related lower limb injuries. Sports Med; 26(6): 395-413

Learning Objectives
Be able to discuss the multifactorial nature of sports injuries
Have a detailed knowledge of the intrinsic and extrinsic risk factors as they apply to common overuse lower limb sports injuries

The Numbers
3-5 million injuries per/year in USA (Kraus & Conroy, 1984)
World-wide cost of $1 billion annually (Egger, 1990)
Personal cost?


The Aetiology of Injury
Normal structure and function but inadequate preparation or excessive demands placed on tissues.
Abnormal structure and function with relatively “normal” demands placed on tissues.

Intrinsic Causes of Injury
Age
Physical build
Height
Bodyweight
Body fat
Body mass index
Gender
Previous injury
Malalignment
Physical fitness
Laxity/Inflexibility
Others..
Systemic factors
Inadequate nutrition
Diseases

Age
Changes in aging may predispose to injury
Reduced muscle strength and size
Bone mass declines after 2nd-3rd decades
Cardiac output 20% less than young adult
Respiratory work increases 20%
Reduced nerve conduction velocity
Increase in obesity
These are associations, due to disuse rather than aging!
Controversial: some evidence to support as a risk factor
>24 years: increased likelihood for injury (military studies)

Physical Build
Height
Males: no correlation
Females: shortest and tallest quartiles 1.7 times more likely to develop injury (military populations)
Shorter females with shorter stride length overstride to keep pace
Taller stature – higher C of G, greater length of limbs or mechanical loading??

Body weight
Not borne in the literature (military populations)
Recalcitrant heel pain associated with large body weight

Percentage body fat
Controversial
No relationship between body fat and injury risk (military populations)
Higher body fat in males may predispose to injury (Rayson et al., 1996)

Body Mass Index (BMI)
BMI = bodyweight/height2 (kg/m2)
Normal 18-25
Above or below doubles the injury risk

Gender
Injury rates have been 2-4 times higher in female military recruits than males (Jones et al. 1988; Bensel et al., 1983; Ross et al. 1994; Yates & White, 2002)

May be explained by differences in fitness
Females have reduced cardiac output, blood volume, haemoglobin, length of Achilles, wider pelvis, more body fat
Other factors…overstriding to keep up in military studies

Unclear in civilian populations?

Types of injury may also vary between sexes

Female Injuries
ACL ruptures
Stress fractures
Relative risk F ~1.2 to 10.0 times > M (Brukner et al., 1999)



Unhappy triad


Smith A (1996). The Female Athlete Triad: Causes, Diagnosis, and Treatment. The Physician and Sports Medicine; 24(7) July.
http://www.physsportsmed.com/issues/1996/07_96/smith.htm


Male Injuries
Males have three-fold higher risk of ankle injuries (Lindenfeld et al., 1994)

Previous injury
Previous injury/inadequate rehabilitation/premature return to activity
May increase the risk of developing a new injury by 2-3 fold

Injured structures are prone to further injury
Compensation in a more distal site may result in pathology in that area

Malalignment
LLD, hip, knee, ankle and foot

Little agreement about characterisation of abnormal alignment or methods of assessment
Reliability and validity issues
Different activities studied
Controversial!!!


Limb length discrepancy
Back and hip pain
Stress fractures
Sciatica
Knee pain
Fasciitis
ITB syndrome or ‘shin splints’
Usually longer leg


Hip (Neely, 1998)

Excessive femoral anteversion suggested to cause PFJPS (literature not supported)
Excessive femoral retroversion increases risk of lower limb stress fracture by 2

Knee and ankle
Reduced femoral intercondylar notch width associated with ACL tears (Souryal & Freeman, 1993; LaPrade & Burnett, 1994)

?Increased Q-angle greater than 15° risk factor for overuse injury (military recruits: Cowan et al., 1996)

Genu varum/tibial varum (norm ~ 7° valgus)

Ankle sprains and ‘shin pain’ (Beynnon et al, 2001; Wen et al., 1998)

?Genu valgum risk factor for overuse injury (confirmed: Cowan et al., 1996; not confirmed Milgrom et al., 1987; Giladi et al., 1987; Fairbank et al., 1984)

Ankle/foot
Limited ankle dorsiflexion
Controversial - Up to ~5 fold higher risk of metatarsal stress fractures and midfoot/forefoot pain (Hughes, 1985; DiGiovanni et al., 2002)

Foot type
Controversial
No association between foot type and overuse injury
(Twellar et al., 1997; Wen et al., 1998; Beynnon et al., 2001; Barrett et al., 1993; Finestone et al., 1991; Milgrom et al., 1991)

Association between foot type and injury
Yates and White (unpublished)
MTSS in pronated feet

Dahle et al. (1991)
Supinated and pronated feet associated with knee pain but not ankle sprains

Cowan et al. (1993)
High arched feet a risk factor for foot and knee injuries

Williams et al. (1987)
High arched feet – more lateral structure, bony, foot/ankle injuries, fasciitis, ITB syndrome, inversion sprains, 5th met stress #s

Low arched feet – more medial structure, soft tissue and knee injuries, general knee pain, fasciitis, 2nd and 3rd met stress #s

Physical Fitness
reviewed by Neely (1998)

Less fit individuals approximately 2-3 fold more likely to be injured during basic training (endurance fitness - run times)
Those with history of more previous activity (work, leisure and sport) incur fewer injuries in training

Physical Build
Stronger athletes may be more at risk. Why?
Increased activity levels?
Increased forces?
Psychological factors?
Studies unclear as to whether those who are stronger have reduced/increased injury rates (reviewed by Neely, 1998)

Laxity, flexibility and muscle tightness
Reviewed by Neely (1998)

Laxity
Normal variation of looseness without traumatic alteration
Effects on injury rates are controversial
Excessive flexibility (laxity) may predispose to knee and ankle ligament sprains
Excessive muscle tightness (hamstring, calf, hip muscles) theorised as a cause of muscle strains but this is not supported

Limited ankle joint dorsiflexion
Trends for increase in stress fractures, medial tibial stress syndrome and ITB syndrome


Extrinsic Causes of Injury
Sporting Activity
Level of competition
Skill Level
Shoe Type
Playing surface
Training errors

Sporting Activity
The type of sport and technique used are integral to the injury development
Understand the forces involved in the sport
Identify the structures at risk of injury
Determine the biomechanical mechanism of injury
Use this in the treatment plan

Level of competition
Up to 25-30 fold greater risk of traumatic injury during competition versus training (Seil et al., 1998; Prager et al., 1989; Messina et al., 1999; Mielson & Yde, 1989; Ekstrand et al., 1983)
Increased aggression, risk-taking behaviours

Skill level
Controversial

Two-fold higher risk in younger soccer players with low skill level (Peterson et al., 2000;Chumiak & Lung, 2000)

Up to two-fold increase risk in netball or basketball athletes with high skill (Hopper et al., 1995; Hosea et al., 2000)

More aggressive intensity for skilled athletes


Shoe type
Inappropriate, worn out (Brukner et al., 1999)

No evidence

Controversial
Small reduction in metatarsal stress fractures and foot injuries using basketball versus infantry boots (Milgrom et al., 1992)


No difference in ankle sprains for low top, high top and high top with inflatable chamber shoes in basketballers (Barrett et al., 1993)

~Four-fold increase in ankle sprains for basketball shoes with air cells in heels versus basketball shoes without air cells (McKay et al., 2001)

Increased number of ACL tears in American footballers wearing irregular cleats positioned at shoe periphery versus flat, screw-in and pivot disk-designs (Lambson et al., 1996)


Playing surface
Hard surfaces (Brukner et al., 1999)
Increased shock
~Two-fold increase of foot/ankle, knee and lower back injuries for artificial turf compared to grass or gravel (Powell, 1987; Arnason et al., 1996)

Cambered surfaces (Brukner et al., 1999)
Increased muscular compensation

Training Errors
Commonest cause of injuries (‘too much too soon’)
Excessive volume, intensity or fatigue
Rapid increase
Inadequate recovery
Faulty technique

Increased frequency (3 versus 5 days/week), duration (15-30 versus 45 min/day) and distance (>32 km/week of running increases risk overuse injury incidence in novice runners (Yeung & Yeung, 2001)


Summary
Be able to discuss the multifactorial nature of sports injuries
Have a detailed knowledge of the intrinsic and extrinsic risk factors as they apply to common overuse lower limb sports injuries