Chapter 121 - Common sporting injuries

Exercise and temperance can preserve something of our early strength even in old age.

Cicero (106-43 BC)

Although there is considerable overlap between injuries occurring during everyday activities and those of sporting and recreational activities, there are many injuries that are characteristic to sports people. Many of these injuries are the result of trauma of various degree and include the many varieties of fractures, dislocations and soft tissue injuries.Injuries to the eyeBlunt injuries to the eye are common in sport. Examples include tennis and squash balls, cricket balls and baseballs, and fistsand fingers associated with body contact sports. Haemorrhage is the most common problem and occurs throughout the eye: subconjunctivally; in the anterior chamber (hyphaema); into the vitreous; and underneath the retina or choroid.Another common problem is a corneal abrasion where a small wound can be caused by a foreign body, a fingernail or a contact lens. It needs to be treated with great respect.HyphaemaWith hyphaema, bleeding from the iris collects in the anterior chamber of the eye. The danger is that, with exertion, asecondary bleed from the ruptured vessel could fill the anterior chamber with blood, blocking the escape of aqueous humour and causing a severe secondary glaucoma. Loss of the eye can occur with a severe haemorrhage. It is likely to happen between the second and fourth day after the injury.Management

First, exclude a penetrating injury.Avoid unnecessary movement: vibration will aggravate bleeding. (For this reason, do not use a helicopter if evacuation is necessary.)Avoid smoking and alcohol.Do not give aspirin (can induce bleeding).Prescribe complete bed rest for 5 days and review the patient daily. Apply padding over the injured eye for 4 days.Administer sedatives as required.Beware of 'floaters', 'flashes' and field defects.

Arrange ophthalmic consultation after one month to exclude glaucoma and retinal detachment. No sport before this time. Generally, recovery runs an uneventful course. If secondary bleeding occurs (usually the second, third or fourth day) the patient should be transported immediately to the nearest eye hospital. Evacuate by air (not by helicopter) only if the cabin altitude can be kept below 1300 metres (4000 feet). It is important to prevent vomiting and expansion of air within the eye. Protective spectacles should always be worn when playing squash. People with monocular vision should be advised not to participate in this sport.Knocked out or broken teethIf a permanent (second) tooth is knocked out it can be saved by immediate proper care. Likewise, a broken tooth should besaved and urgent dental attention sought.The knocked-out tooth

Place the tooth in its original position, preferably immediately ( Fig 121.1 ): if dirty, put it in milk before replacement or, better still, place it under the tongue and 'wash it' in saliva. Do not use water, and do not wipe or touch the root.Fix the tooth by moulding strong silver foil (e.g. a milk bottle top or cooking foil) over it and the adjacent teeth. Refer the patient to his or her dentist or dental hospital as soon as possible.

Note: Teeth replaced within half an hour have a 90% chance of successful reimplantation.

Fig. 121.1 Replacement of a knocked-out tooth

General Practice, Chapter 121

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Injuries to the noseCommon injuries to the nose include epistaxis and fractures of the nasal bones.EpistaxisFirst aid is simple tamponade, which is invariably effective. The soft cartilaginous part of the nose should be pinched betweenthe finger and thumb for 5-10 minutes. The head should be kept bent slightly forward. Packing of the nose may be required.Fracture of the noseIf deformity is present the patient should be referred for reduction within 7 days.Septal haematomaSpecial care has to be taken of a septal haematoma, which has a tendency to become infected ( click here for furtherreference).Shoulder injuriesCommon shoulder injuries acquired in sporting activities include:

dislocated or subluxed acromioclavicular joint ( click here for further reference) fractured clavicle ( click here for further reference)dislocated shoulder ( click here for further reference) supraspinatus tendinitis ( click here for further reference)

Swimmer's shoulderPainful shoulders occur in about 60% of elite level swimmers during their career. The basic disorder is rotator cuff tendinitis,particularly supraspinatus tendinitis, which is considered to be associated with abnormal scapular positioning and cervicothoracic dysfunction. The best treatment is prevention, which aims at rotator cuff strengthening exercises, better scapulothoracic control, including correction of thoracic extension if it is decreased, and scapular stabilisation exercises. 1Elbow injuriesSoft-tissue disorders of the elbow are extremely common. Two types of tennis elbow are identifiable. 'Backhand' tennis elbow orlateral epicondylitis ( click here for further reference) and 'forehand' tennis elbow or medial epicondylitis, which is also known as golfer's elbow or baseball pitcher's elbow. These common problems, often unrelated to sporting activity, are presented in more detail in Chapter 58 .Hand injuriesHand and finger injuries are very important in sporting activities and include fractures and dislocations of phalanges andmetacarpals. A mallet finger is a common injury and can result from overuse.Ligamentous disruption of finger joints can cause instability and require early referral. An example is gamekeeper's thumb, often encountered in skiers, where there is complete tearing of the medial ligament of the metacarpophalangeal joint.Mallet fingerA mallet finger is a common sports injury caused by the ball (football, cricket ball or baseball) unexpectedly hitting the finger tipand forcing the finger to flex. Such a forced hyperflexion injury to the distal phalanx can rupture or avulse the extensor insertion into its dorsal base. The characteristic swan neck deformity is due to retraction of the lateral bands and hyperextension of the proximal interphalangeal joint.The 45 guidelineWithout treatment, the eventual disability will be minimal if the extensor lag at the distal joint is less than 45; a greater lag will result in functional difficulty and cosmetic deformity.TreatmentMaintain hyperextension of the distal interphalangeal joint for 6 weeks, leaving the proximal interphalangeal joint free to flex.Equipment

Friar's balsam (will permit greater adhesion of tape)Non-stretch adhesive tape, 1 cm wide: two strips approximately 10 cm in length

Method

1. Paint finger with Friar's balsam (compound benzoin tincture).2. Apply the first strip of tape in a figure of eight configuration. The centre of the tape must engage and support the pulp of the finger. The tapes must cross dorsally at the level of the distal interphalangeal joint and extend to the volar aspect of the proximal interphalangeal joint without inhibiting its movement ( Fig 121.2 a ).3. Apply the second piece of tape as a 'stay' around the midshaft of the middle phalanx ( Fig 121.2 b ).

Reapply the tape wherever extension of the distal interphalangeal joint drops below the neutral position (usually daily,

depending on the patient's occupation). Maintain extension for 6 weeks.

Fig. 121.2 Mallet finger: (a) application of first tape; (b) application of 'stay' tape

SurgeryOpen reduction and internal fixation are reserved for those cases where the avulsed bony fragment is large enough to cause instability, leading to volar subluxation of the distal interphalangeal joint.Tenpin bowler's thumbTenpin bowler's thumb is a common stress syndrome in players. It usually presents as a soft-tissue swelling at the base of thethumb web, with associated pain and stiffness of the digits used for bowling. It may cause a traumatic neuroma of the digital nerve at this site with associated hyperaesthesia.Management

rest massagebevel the bowling ball holes to reduce frictionan intralesional injection ( Fig 121.3 ) of 0.25 mL of long-acting corticosteroid mixed with local anaesthetic (resistant cases)

Fig. 121.3 Tenpin bowler's thumb

Snow skiing injuriesThe most common injuries encountered in snow skiing are soft-tissue injuries and fractures and dislocations.A study by Robinson showed that the six most common skiing injuries were: strains to the medial collateral ligament of the knee 24.3%; contusions of soft tissue (excluding head and neck) 17.6%; lacerations 15.5%; neck and back injuries 7.8%; fractures 7.6%; and dislocations. 2There has been a large decrease in injuries relative to participation in the past decade because of improved equipment and attention to safety. The most common fractures in skiers are those involving the tibia and fibula, especially spiral fractures. Other common fractures are of the clavicle, wrist and humerus. Dislocation of the shoulder region (glenohumeral joint and acromioclavicular joint) are due to falls on hard impacted snow.Skier's thumb 3A special injury is skier's thumb (also known as gamekeeper's thumb) in which there is ligamentous disruption of themetacarpophalangeal joint with or without an avulsion fracture of the base of the proximal phalanx at the point of ligamentous attachment. This injury is caused by the thumb being forced into abduction and hyperextension by the ski pole as the skier pitches into the snow.Diagnosis is made by X-ray with stress views of the thumb. Incomplete tears are immobilised in a scaphoid type of plaster for 3 weeks, while complete tears and avulsion fractures should be referred for surgical repair.Spinal problemsSpinal dysfunction, particularly of the neck and low back, are very common problems in sport, as for the general population.

Serious problems include pars interarticularis fractures, spondylolisthesis, disc disruptions with prolapse and, rarely, vertebral body fracture. The common problems are the various facet joint syndromes and musculoskeletal strains, which are managed conservatively as outlined in Chapters 33 and 56 . The key to management is a conservative approach with a back education and exercise program.Injuries to the lower limbsInjuries due to trauma and overuse of the lower limbs comprise the most frequent group of sports-related disorders requiringmedical attention.The three main causes of overuse trauma are:

friction, e.g. peritendinitisstress or overload, e.g. hamstring tear, tibial stress fracture ischaemia, e.g. anterior compartment syndrome

Overuse leg syndromesIncreased community participation in physical activity, including running and jogging, has resulted in a concomitant increase inoveruse leg injuries, especially in the lower leg with its weight-bearing load. The common cause is repetitive trauma where the forces involved overwhelm the tissue's ability to repair adequately. Common causes of chronic leg pain include hamstring injuries and injuries to the lower leg.Principles of managementPrevention:

maintain ideal weight good nutrition adequate preparationwarm-up exercises for the legs proper footwearproper activity planning

Treatment of injury

Rest, or relative rest: the patient is allowed to perform activities that do not aggravate the injury.Ice: apply an ice pack for 20-30 minutes every 2 hours while awake during the first 48-72 hours post injury. Compression: keep the injured muscle or tissue firmly bandaged for at least 48 hours.Elevation: rest the leg on a stool or chair until the swelling subsides.Correction of predisposing factors (intrinsic or extrinsic), e.g. orthotics for malalignment, correction of training errors. NSAIDs for painful inflammatory response.Physical therapy, e.g. stretching, mobilisation when acute phase settled.

Groin painGroin pain is a particularly common condition among athletes.Acute groin painAcute conditions such as muscle and musculotendinous strains, 4 and overuse injuries such as tendinitis and tendoperiostitis,are generally readily diagnosed and treated. Diagnostic difficulties can arise because of referred pain from the lumbosacral spine, hip and pelvis. More common acute groin injuries include injuries to the following muscles and their tendons ( Fig 121.4).

adductor longus, e.g. musculotendinous strains rectus femorissartorius iliopsoas

Other injuries include:

SUFE in adolescentsavulsion fractures in adolescents, e.g. rectus femoris and sartorius on the iliac spines

Fig. 121.4 Muscles in the groin region subject to musculotendinous injuries in the athlete

Chronic groin painThere are many causes of chronic groin pain, with bone and joint abnormalities being more likely causes. Important causesinclude:

muscle and musculotendinous lesions, e.g. adductor longus tendoperiostitis bursitis, e.g. iliopsoas bursitisosteitis pubis (pubic symphysis)stress fractures, e.g. femoral neck and pubic ramisacroiliac and hip joint disorders, e.g. osteoarthritis hip/tumour lumbar spine: L1/L2 or L2/L3 disc'occult' inguinal or femoral hernia

Investigations

X-ray of pelvis (AP, lateral, oblique)tomography of pubic symphysis (to detect osteitis pubis and pubic instability) bone scan to detect stress fractures or osteitis pubisherniographyCT scan or MRI or ultrasound (increasing potential)

Jock itchJock itch, or tinea cruris, is a common infection in the groin area of young men, especially athletes, who are subjected tochaffing in the groins from tight shorts and nylon 'jock straps'. The feet should be inspected for evidence of tinea pedis. The dermatophyte is transmitted by towels and other objects, particularly in change rooms and communal showers ( click here for further reference).Hamstring injuriesHamstring strains are common in athletes. The short head of biceps femoris is the most commonly strained component of thehamstring group. Clinical features:

a history of a 'pull', 'twinge', 'tear' or 'twang' in the back of the thigha soreness and lump develops (with a severe tear a person can collapse) localised tendernesslimitation of straight leg raisingpain on resisted or active knee flexion or hip extension bruising (usually in popliteal fossa) may be present

ManagementThe immediate goals of treatment of the acute injury are to relieve pain and minimise swelling.

RICE for 72 hoursNSAIDs, e.g. aspirin or indomethacin stretching exercisespassive stretching after ice treatment then active stretching

then isometric contraction exercises

Haematomas in muscle ('corked thigh')Haematomas can be intramuscular, intermuscular or interstitial. They usually result from a sharp blow, e.g. knee to the thigh orkick in the anterior compartment of the leg.An intramuscular haematoma can cause an acute compartment syndrome which may require urgent decompression. One objective of treatment is to prevent excessive scarring. Other complications include infection, cyst formation, thrombophlebitis and myositis ossificans.Management

RICE treatment with emphasis on cooling non-weight-bearing, using crutches initiallyconsider admission to hospital or a day surgical unit to check progressreferral for expert advice may be appropriate because of the potentially serious nature of the injury

Injuries to the kneeKnee injuries are common, have multiple clinical disorders and are potentially disastrous to the athlete. The various injuries andoveruse syndromes are presented in considerable detail in Chapter 61 , on the painful knee.Acute injuriesAcute injuries ( click here for further reference) include:

meniscal tearsligamentous tears and strains (of varying degrees) anterior cruciate ligamentposterior cruciate ligament medial collateral ligament lateral collateral ligament

Overuse syndromesThe knee is very prone to overuse disorders ( click here for further reference). The pain develops gradually without swelling, isaggravated by activity and relieved with rest. It can usually be traced back to a change in the sportsperson's training schedule, footwear, technique or related factors. It may also be related to biomechanical abnormalities, ranging from hip disorders to disorders of the feet.Overuse injuries include:

patellofemoral pain syndrome (jogger's knee/runner's knee) patellar tendinitis (jumper's knee)synovial plica syndrome infrapatellar fat-pad inflammation anserinus bursitis/tendinitis biceps femoris tendinitissemimembranous bursitis/tendinitis quadriceps tendinitis/rupture popliteus tendinitisiliotibial band friction syndrome (runner's knee) the hamstrung knee

A careful history followed by systematic anatomical palpation around the knee joint will pinpoint the specific overuse syndrome.Overuse injuries to lower legA summary of the clinical and management aspects of various injuries is presented in Table 121.1 and in Figure 121.5 .Common causes of chronic lower leg pain in sportspeople include: 5

medial tibial stress syndrome (previously called shin splints) stress fractures ( Fig 121.6 )exertional compartment syndrome, especially anterior compartment tibialis anterior tenosynovitis ( Fig 121.7 )chronic muscle strains

These problems are invariably due to excessive physical demands in athletes striving for the ultimate performance or in the

occasional athletes who have made inadequate preparation for their activity. Training errors contribute to a large proportion (60%) of overuse injuries. 5

Fig. 121.5 Common sites of overuse injuries in the lower leg

Fig. 121.6 Typical sites of stress fractures in athletes in the tibia and fibula

Fig. 121.7 Site of tibialis anterior tenosynovitis

Table 121.1 Clinical comparisons of overuse syndromes in lower leg

SyndromeSymptomsCauseTreatment

Anterior compartment syndrome

Iliotibial band tendinitis

Tibial stress syndrome or shin splints

Tibial stress fracture

Tibialis anterior tenosynovitis

Achilles tendinitis

Pain in the anterolateral muscular compartment of the leg, increasing with activity. Difficult dorsiflexion of foot, which may feel floppy.

Deep aching along lateral aspect of knee or lateral thigh. Worse running downhill, eased by rest. Pain appears after 3-4 km running.

Pain and localised tenderness over the distal posteromedial border of the tibia. Bone scan for diagnosis.

Pain, in a similar site to shin splints, noted after running. Usually relieved by rest. Bone scan for diagnosis.

Pain, over anterior distal third of leg and ankle. Pain at beginning and after exercise swelling, crepitus. Pain on active or resisted ankle dorsiflexion.

Pain in the Achilles tendon aggravated by walking on the toes. Stiff and sore in the morning after rising but improving after activity.

Persistent fast running1.g. squash, football, middle-distance running).

Running up hills by long- distance runners and increasing distance too quickly.

Running or jumping on hard surfaces.

Overtraining on hard (often bitumen) surfaces.Faulty footwear.

Overuseexcessive downhill running.

Repeated toe running in sprinters or running uphill in distance runners.

Modify activities.Surgical fasciotomy is the only effective treatment.

Rest from running for 6 weeks.Special stretching exercises.Correct training faults and footwear.? injection of LA and corticosteroids deep into tender areas.

Relative rest for 6 weeks. Ice massage.Calf (soleus stretching). NSAIDs.Correct training faults and footwear.

Rest for 6-10 weeks. Casting not recommended. Graduated training after healing.

Rest, even from walking. Injection of LA and corticosteroid within tendon sheath.

Relative rest.Ice at first and then heat. 10 mm heel wedge. Correct training faults and footwear.NSAIDs.

Principles of treatment

1. rest or relative rest2. exercise program (where appropriate)3. correction of predisposing factors, e.g. training errorsunsuitable footwear inadequate warm-up malalignment4. analgesics: use NSAIDs only if it is true inflammatory pain (pain at rest)

Stress fracturesStress fractures are an important cause of lower leg pain and foot pain in sport, accounting for 5-15% of injuries. 5 Stressfractures occur in the tibia and fibula and in the foot (navicular, calcaneus and metatarsals). The important clinical factor is to keep stress fractures in mind and X-ray the tender area. If the X-ray is negative and there is a high index of suspicion, a radionuclide scan should be ordered.In the tibia, stress fractures occur mainly in the proximal metaphysis and the junction of the middle and distal thirds of the shaft. In the fibula they usually occur 5-7 cm above the tip of the lateral malleolus ( Fig 121.6 ).These stress fractures usually occur after prolonged and repeated heavy loading such as long-distance running or repeated

jumping.Torn 'monkey muscle'The so-called torn 'monkey muscle', or 'tennis leg', is actually a rupture of the medial head of gastrocnemius at themusculoskeletal junction where the Achilles tendon merges with the muscle ( Fig 121.8 ). It is not a torn plantaris muscle as commonly believed. This painful injury is common in middle-aged tennis and squash players who play infrequently and are unfit.Clinical features:

a sudden sharp pain in the calf (the person thinks he/she has been struck from behind, e.g. a thrown stone) unable to put heel to groundwalks on tip toeslocalised tenderness and hardness dorsiflexion of ankle painful bruising over site of rupture

Fig. 121.8 'Tennis leg' or 'monkey muscle'illustrating typical site of rupture of the medial head of gastrocnemius at the junction of muscle and tendon (left leg)

Management

RICE treatment for 48 hoursice packs immediately for 20 minutes and then every 2 hours when awake (can be placed over the bandage) a firm elastic bandage from toes to below the kneecrutches can be used if severea raised heel on the shoe aids mobilitycommence mobilisation after 48 hours rest, with active exercisesphyiotherapist supervision for gentle stretching massage and then restricted exercise

Sprained ankleThere are two main ligaments that are subject to heavy inversion or eversion stresses, namely the lateral ligaments and themedial ligaments respectively. Most of the ankle 'sprains' or tears involve the lateral ligaments (up to 90%) while the stronger tauter (deltoid) ligament is less prone to injury.The lateral ligament complex involves three main bands: the anterior talofibular (ATFL), the calcaneofibular (CFL) and the posterior talofibular ligament (PTFL) ( Fig 121.9 ).

Fig. 121.9 Lateral ligaments of the ankle

Mechanism of injury to lateral ligaments 6Forced inversion causes about 90% of all ankle injuries.Most sprains occur when the ankle is plantar-flexed and inverted such as when landing awkwardly after jumping or stepping on uneven ground.InversionFoot in plantar flexion: ATFL injury likely (50-60%) Foot in neutral: CFL injury likely (10%)Foot in dorsiflexion: PTFL injury likely (5%)

Note: Combined ATFL and CFL injury (15-25%).EversionFoot in plantar flexion or neutral: medial ligament (mainly anterior part) The classification of ankle injuries is presented in Table 121.2 .Table 121.2 Classification of injuries to ankle ligaments (adapted from Litt) 6

GradeFunctional/clinicalLigamentous stability

Stress X- rays

I(mild)

II(moderate)

minimal pain and swelling minimal bleedingfull range of motion heel and toe walking

moderate to severe pain and swelling

considerable bleeding decreased range of motion difficulty in weight bearing and ambulation

minor ligamentous injury with only a partial tear of the ligamentstable ankle joint

similar to Grade I only more severe partially unstable joint

normal

anterior draw 4-14 mmTalar tilt 5-10

III(severe)

minimal to severe pain and swelling pronounced bleedingminimal range of motion unable to weight bear

complete ligamentous rupture with unstable jointanterior draw> 15 mm Talar tilt > 20

Clinical features of sprained lateral ligamentsCommon features

ankle 'gives way'difficulty in weight bearing discomfort varies from mild to severebruising (may take 12-24 hours) indicates more severe injury

may have functional instability: ankle gives way on uneven ground

Physical examination (perform as soon as possible)

note swelling and bruisingpalpate over bony landmarks and three lateral ligaments test general joint laxity and range of motiona common finding is rounded swelling in front of lateral malleolus (the 'signe de la coquille d'oeuf') test stability in AP plane (anterior draw sign)talar tilt test (inversion stress test)

Is there an underlying fracture? 7For a severe injury the possibility of a fractureusually of the lateral malleolus or base of fifth metatarsalmust be considered. If the patient is able to walk without much discomfort straight after the injury, a fracture is unlikely. Indications for X-ray include: 7

inability to weight bear immediately after injury marked swelling and bruising soon after injury marked tenderness over the bony landmarks marked pain on movement of the ankle crepitus on palpation or movementpoint tenderness over the base of the fifth metatarsal special circumstances, e.g. litigation potential

ManagementThe treatment of ankle ligament sprains depends on the severity of the sprain. Most grade I and II sprains respond well tostandard conservative measures and regain full, pain-free movement in 1-6 weeks, but controversy surrounds the most appropriate management of grade III sprains.Grade I sprain

1. rest the injured part for 48 hours, depending on disability2. ice pack for 20 minutes every 3-4 hours when awake for the first 48 hours3. compression bandage, e.g. crepe bandage4. elevate to hip level to minimise swelling5. analgesics, e.g. paracetamol codeine6. review in 48 hours, then 7 days7. special strapping

Use partial weight bearing with crutches for the first 48 hours or until standing is no longer painful, then encourage early full weight bearing and a full range of movement with isometric exercises. 7 Use warm soaks, dispense with ice packs after 48 hours. Walking in sand, e.g. along the beach, is excellent rehabilitation. Aim towards full activity by 2 weeks.

Special strappingA firm support for partial tears in the absence of gross swelling provides excellent symptomatic relief and early mobilisation.

Method

Maintain the foot in a neutral position (right angles to leg) by getting patient to hold the foot in that position by a long strap or sling.Apply small protective pads over pressure points.Apply one or two stirrups of adhesive low-stretch 6-8 cm strapping from halfway up medial side, around the heel and then halfway up the lateral side to hold foot in slight eversion ( Fig 121.10 a,b ).Apply an adhesive bandage, e.g. Acrylastic (6-8 cm) which can be rerolled and reused. Reapply in 3-4 days.After 7 days, remove the bandage and use a non-adhesive tubular elasticised support until full pain-free movement is achieved.

Fig. 121.10ab Supportive strapping for a sprained ankle: Step 1 apply protective pads and stay tape; Step 2 apply stirrups tohold foot in slight eversion

Fig. 121.10c Supportive strapping for a sprained ankle: Step 3 apply an ankle lock tape

Grade II sprainRICE treatment (as above) for 48 hours but ice, e.g. ACE wrap, should be every 2-3 hours and no weight bearing (use crutches) for 48 hours. Then permit partial weight bearing with crutches and begin the active exercise program. Follow-up and supportive strapping as for Grade I. Note that the ice packs can be placed over the strapping.Grade III sprainIt would be appropriate to refer this patient with a complete tear. Initial management includes RICE and analgesics and an X- ray to exclude an associated fracture. The three main treatment approaches appear to be equally satisfactory.

Surgical repairSome specialists prefer this treatment but it is usually reserved for the competitive athlete who demands absolute stability of the ankle.

Plaster immobilisationThis is usually reserved for patients who are unable actively to dorsiflex their foot to a right angle and those who need to be mobile and protected in order to work. The plaster is maintained until the ligament repairs, usually 4-6 weeks. The patient can walk normally when comfortable with a rockered sole or open cast walking shoe.

Strapping and physiotherapyThis approach is generally recommended. After the usual treatment for a Grade II repair, including the strapping as described, a heel lock ( Fig 121.10 c ) should be used. The patient continues on crutches and appropriate physiotherapy is given with care so that the torn ends are not distracted. Strengthened balance is achieved by the use of elastic bands, swimming and cycling.Non-response to treatmentThere are some patients who, despite an apparently straightforward ankle sprain, do not respond to therapy and do not regain a full range of movement. In such patients alternative diagnoses in addition to ligament tearing must be considered ( Table121.3 ). These require careful clinical assessment and further investigation such as bone scans.Table 121.3 Unstable ankle injuries to be considered in delayed healing (after Brukner) 7

Osteochondral fracture of the talar dome Dislocation of the peroneal tendons Sinus tarsi syndromeAnteroinferior tibiofibular ligament injury Post-traumatic synovitisAnterior impingement syndrome Posterior impingement syndrome Anterior lateral impingement Rupture of posterior tibial tendon Reflex sympathetic dystrophyOther fractures base 5th metatarsal (avulsion) lateral process of talus anterior process of the calcaneus tibial plafond stress fracture navicular

Heel disordersImportant causes of heel pain and other disorders resulting from overuse sporting activities include:

Achilles tendon disorders tendinitis/peritendinitis tear: partial or completebruised heel'pump bumps'/bursitis calcaneal apophysitisplantar fasciitis ( click here for further reference) talon noirblisters

Achilles tendinitis/peritendinitis 9The inflammation that occurs as a combination of degenerative and inflammatory changes due to overuse may appear either inthe tendon itself or in the surrounding paratendon. The latter is called peritendinitis rather than tenosynovitis because there is no synovial sheath.

Clinical features:

history of unaccustomed running or long walk common in runners who change routine usually young to middle-aged malesaching pain on using tendontendon feels stiff, especially on rising tender thickened tendonpalpable crepitus on movement of tendon

Ultrasound examinationThis is very useful in differentiating between tendinitis, peritendinitis, focal degeneration and a partial tear.Preventive measures

warm-up and stretching exercises in athletes good quality shoes1 cm heel raise

Treatment

Rest: ? crutches in acute phase, plaster cast if severe Cool with ice in acute stage, then heatNSAIDs1-2 cm heel raise under the shoe ultrasound and deep friction massagemobilisation, then graduated stretching exercises

Note: Ensure adequate rest and early resolution because chronic tendinitis is persistent and very difficult to treat.Avoid corticosteroid injection in acute stages and never give into tendon. Can be injected around the tendon if localised and tender.Partial rupture of Achilles tendonClinical features:

a sudden sharp pain at the time of injury sharp pain when stepping off affected legusually males >30 sporadically engaged in sport history of running, jumping or hurrying up stairsa tender swelling palpable about 2.5 cm above the insertion may be a very tender defect about size of tip of little finger

TreatmentIf palpable gapearly surgical exploration with repair. If no gap, use conservative treatment:

initial rest (with ice) and crutches 1-2 cm heel raise inside shoeultrasound and deep friction massage graduated stretching exercises

Convalescence is usually 10-12 weeks. 8 A poor response to healing manifests as recurrent pain and disability, indicates surgical exploration and possible repair.Complete rupture of Achilles tendonThis common problem in athletes occurs in a possibly degenerated tendon subjected to a sudden increased load, e.g. a skierwith foot anchored and ankle dorsiflexed. Clinical features:

sudden onset of intense pain patient usually falls overfeels more comfortable when acute phase passes development of swelling and bruisingsome difficulty walking, especially on tip toe

Diagnosis

palpation of gap (best to test in first 2-3 hours as haematoma can fill gap) positive Thompson's test ( Fig 121.11 a,b )

Note: The injury may be missed because the patient is able to plantar flex the foot actively by means of the deep long flexors to the foot.

Fig. 121.11 Thompson's calf squeeze test for ruptured Achilles tendon: (a) intact tendon, normal plantar flexion; (b) rupturd tendon, foot remains stationary

TreatmentEarly surgical repair (within 3 weeks).'Pump bumps'A 'pump bump' is a tender bursa over a bony prominence lateral to the attachment of the Achilles tendon. This is caused byinflammation related to poorly fitting footwear irritating a pre-existing enlargement of the calcaneus. Treatment is symptomatic and attention to footwear.Talon noirTalon noir or 'black heel', which has a black spotted appearance on the posterior end of the heel, is common in sportsmen andwomen, especially squash players. It tends to be bilateral and is caused by the shearing stresses of the sharp turns required in sport. The diagnosis is confirmed by gentle paring away of the hard skin containing old blood.Disorders of the feet and toesCommon problems include:

fractures of toes foot strain ingrowing toenails 'black' nailsbony outgrowth under the nail (subungual exostosis) callusesathlete's foot (tinea pedis) plantar warts

Black nails ('soccer toe')Black or 'bruised' nails are due to subungual haematoma caused by trauma. The problem can be acute or chronic and is seenin the great toes. Acute cases are usually the result of the toe being trodden on, while chronic cases are the result of wearing ill-fitting shoes (too narrow or loose) or the toenails being left too long.The problem is encountered commonly in sports that involve deceleration forces and include running (especially cross-country with downhill running), netball, basketball, tennis, football and skiing.TreatmentAn acute subungual haematoma should be decompressed with a hot needle or other procedure through the nail. A chronic non-painful problem should be left to heal. The toenails will become dystrophic and be replaced by 'new' nails.

General Practice, Chapter 121

Attention should be paid to the footwear either by changing it or by placing protective padding in the toes of the running shoes or boots.Injuries in adolescentsIf an adolescent engaged in sport presents with pain in the leg it is important to consider the following problems.

slipped capital femoral epiphysis ( click here for further reference) avulsion of epiphyses, e.g. ischial tuberosity (hamstring)stress fractureOsgood-Schlatter's disorder Scheuermann's disorder idiopathic scoliosis

References

1. Fitzpatrick J. Shoulder pain a real wet blanket. Australian Dr Weekly, 5 February 1993; 56.2. Robinson M. Hazards of alpine sport. Aust Fam Physician, 1991; 20:961-970.3. Elliott B, Sherry E. Common snow skiing injuries. Aust Fam Physician, 1984; 13:570-574.4. Zimmermann G. Groin pain in athletes. Aust Fam Physician, 1988; 17:1046-1052.5. James T. Chronic lower leg pain in sport. Aust Fam Physician, 1988; 17:1041-1045.6. Litt J. The sprained ankle. Aust Fam Physician, 1992; 21:447-456.7. Brukner P. The difficult ankle. Aust Fam Physician, 1991; 20:919-930.8. Sloane PD, Slatt LM, Baker RM. Essentials of family medicine. Baltimore: Williams and Wilkins, 1988, 253-259.9. Bruckner P, Khan K. Clinical sports medicine. Sydney: McGraw-Hill, 1995, 426-435.