Mark E. Lavallee, MD, CSCS, FACSM Director, York Sports Medicine Fellowship, York, PA Team Physician, Gettysburg College, Gettysburg, PA Chairman, USA Weightlifting, Sports Medicine Society, Colorado Springs, CO DISCLOSURES • I have no relevant conflicts of interest or business relationships in relation to the topic of this lecture. • All persons imaged in talk have given their consent OBJECTIVES
After this presentation, the learner will gain an understanding for injuries relating to the leg Skin (lacerations, contusions, infection) Quadriceps (muscle, tendon, hematomas) Hamstring (muscle, tendon) Ilio-Tibial Band Syndrome (ITBS) Myositis Ossificans Compartment Syndrome (Traumatic vs. Exertional) Bone Issues (Occult vs. Stress Fractures, tumors, Physeal Injuries) SKIN: Lacerations/Abrasions
• Skin Lacerations: irrigate, prevent infection. close wound using • Cyanoacralate • Suture • Steri-Strips • Occlusive dressing (Tegaderm) • Surgical staples • prevent infection • Skin Abrasions: irrigate water, clean soap/Hibiclens, prevent infection Tetanus immunization status of athlete SKIN: Lacerations/Abrasions
• Penetrating injuries : Ascertain if object • Retained (Stingray barb or GSW) or Not-retained (Bicycle Spoke) • Size of object • Large Retained Object: Secure object and transport, DO NOT TRY TO REMOVE!! • Extent of muscular, bony, neurologic or vascular injury, • Tetanus immunization status of athlete • Prevent infection SKIN: Superficial Minor Contusions
• Local treatment as you would treat any contusion • Common in FB, Rugby • Thigh protectors seem to decrease incidence • Ice, rest, protection from further injury, stretching • If deep quadriceps contusion, more rigorous protocol is warranted. SKIN: DEEP Quadriceps Contusions
• If deep quadriceps contusion, like FB helmet to quadricep • Place knee hyperflexed position (120 degrees) for 12-24 hours • Assess for Traumatic compartment syndrome for first 24 hours • Crutches • ICE • Image with ultrasound daily for first 3 days to assess size of contusion/ hematoma • Avoid meds that inhibit platelet/ clotting cascade (NSAIDs)
Mountain Biker thrown hit handlebars and root (MEDS: Advil 600mg prior to rides) SKIN: DEEP Quadriceps Hematoma
• If ultrasound shows a substantial quadriceps hemtoma and after 24 hours of of knee hyper-flexion • Reassess with U/S to see is growing. • Generally, you want to attempt to drain these after 24 hours or when it has tampanaded off. • Contoversy: simple aspiration vs aspiartion with intra-luminal corticosteroid or PRP? • Place knee hyperflexed position (120 degrees) for 12-24 hours immediately AFTER aspiration. • Crutches • ICE • Image with ultrasound daily for first 3 days to assess size of hematoma for re-accumilation • Avoid meds that inhibit platelet/ clotting cascade (NSAIDs) SKIN: Quadriceps Myositis Ossificans (MO)
• Myositis ossificans: intramuscular formation of bone (heterotopic bone formation) • MO can develop as LATE complication from a deep quadriceps hematoma. • These develop weeks to months AFTER at quadriceps hematoma has been sustains. • Most are mid-substance of quadriceps and are asymptomatic. • If sxs arise, treatment options should start with stretching, mobilization, and physical therapy. • Treatment with Indomethacin can help stem progress and pain • Surgical excision is rarely needed • Investigational: U/S guided percutaneous ultrasonic debridement (TX1 by TENEX) QUADRICEPS: Strain
• Most common areas of injury are musculotendinous junctions proximally and distally • Muscle belly can also be injured • Treatment with RICE, stretching, HEP • Can take weeks to get over • Less common than hamstring injuries QUADRICEPS: Tendon Rupture
• Younger Athletes: Usually an avulsion from the proximal pole of the patella 1 2 • Older Athletes: Tend to be an inter- 1) Patella Alta S/P Patellar Tendon Tear tendinous rupture 2) Patellar Tilt seen in Quad Tendon • Inquire about uses of anabolic Rupture steroids, creatine, or fluoroquinolones in past 6-12 months • Will be unable to do a straight raise or extend the knee • Will see defect when contract quadricep • Requires operative repair
64yo lifter after WR attempt in C&J, 2014 IWF Worlds, Copenhagen (POD#2) LEFT quad tendon rupture & RIGHT patellar tendon rupture IWF World Masters, Bordeaux, France 2006
Can see Quad retracting, femur
Pat tdn tears
Polish Lifter, C&J 130 kg Same Lifter 8 years later Copenhagen, DEN 2014
Josef Esmont, ended up winning GOLD medal in age/weight class in 2014 Worlds! THIGH Compartment Syndrome: ACUTE
ACUTE is often related to TRAUMA • Seen in combat and collision sports and alpine skiing • Can be associated with: • Large thigh contusion/hematoma • With or without fracture • Blood thinner, ASA, some NSAIDs • EXAM: know the 5 P’s • Pain, Pressure, Pulselessness, Palor, Paresthesia Surgical Fasciotomy used for ACUTE, TRAUMATIC • tense compartment, inability to move or activate muscle COMPARTMENT SYNDROME • Higher likelihood of hematoma THIGH Compartment Syndrome: CHRONIC
• CHRONIC or EXERTIONAL • Reports of exercise induced compartment syndrome of the thigh • NOT a medical emergency • NOT trauma related • SXS: worsen predictably with exercise/activity • EXAM: the 5 Ps AFTER exercise, occasionally at REST, can usually still activate involved muscle, but painful. Rarely involved hematoma
CHRONIC Compartment syndrome shows up MORE in LEG than THIGH THIGH Compartment Syndrome: TESTING
• TEST for EITHER ACUTE or CHRONIC: Compartment pressure testing (STRYKER UNIT) • ABNORMAL: resting pressure >30mmHg • ANATOMY: (know your compartments) • Anterior, Lateral, Medial THIGH: Compartment Syndrome: ANATOMY
• Anterior : quadriceps, iliopsoas, Sartorius, femoral nerve and artery, femur. Gr Saphaneous vein • Posterior : Biceps Femoris, Semi- membranosis, Semi-tendinosis, sciatic nerve • Medial : adductors, cutaneous branch of the obturator nerve, recurrent superficial br. of femoral nerve, deep femoral Artery & vein
Less common than chronic exertional compartment syndrome of the calf/leg as there is more space in the compartments of the thigh THIGH: Compartment Syndrome: TREATMENT
• TREATMENT: • SURGICAL FASCIOTOMY: • More common in acute vs. chronic • Open fasciotomy • Mini-open (small dermal incision over larger fasciotomy) fasciotomy • Laproscopic fasciotomy
• DECONDITIONING (for Chronic Exertional ONLY) • 3-6 months off of intense exercise that caused CECS. • ATROPHY with Fascial planes ILIO-TIBIAL BAND SYNDROME
• Most common cause if “Lateral Hip Pain” • Runners, Overuse? • Non-Athletes: Trauma? Weakness? • Tender to palp, can’t sleep on that side • LATERAL aspect of thigh • PROXIMAL: tensor fascia latta • Greater trochanteric bursa • DISTAL: lateral femoral condyle, near Gerdy’s tubercle ILIO-TIBIAL BAND SYNDROME
• Exam: TIGHT ITB on • OBER’s TEST • Tender to deep palpation • Test for “Snapping Hip” in younger athletes • MOST HAVE POOR PIRIFORMIS STRENGTH • TRMT: NSAIDs, HEP, formal PT, piriformis strengthening • Cortisone injection, if above treatments ineffective,(USE at least a 3.5 inch spinal needle!!) • SURGERY: rarely needed • Bursectomy with Elliptical excision HAMSTRING: Strain
MECHANICISM • Very common sports injury • Avulsion (hyperflexion at the hip) • Waterskiing injury • Football, soccer, hockey, LAX • Sprinters • General population (slip on ice or wet floor) HAMSTRING: Strain
LOCATION • Mid substance injury (usually at the myotendinous junction) • Distal injuries less common • Rapid acceleration and maximum speed running • Often feel a “pop” in back of thigh or near buttocks. 3 days AFTER 10 days AFTER • Occasional palpable defect. HAMSTRING: Strain
BIOMECHANICS: • Eccentric mechanism at the terminal swing phase of gait • Rate of Injury: • Biceps Femoris >>SM>ST • High rates of re-injury • Predisposing factors: • poor or no warm up • poor flexibility, • quad:hamstring ratio of 50% • poor biomechanics HAMSTRING: Strain
TREATMENT • Long time to full recovery 16-50 weeks to pre-injury status • STAGE 1: protect, rest, Ice, Compress, dry needling, meds • STAGE 2: Stretching, modalities, manual therapy • STAGE 3: Dynamic sport-specific drills & “Nordic Eccentric Exercise” • STAGE 4: T/C TX-1 and PRP in recalcitrant cases HAMSTRING: Avulsion fracture/ proximal tendon • Waterskiing hyperflexion injury: Starting on the dock, getting up out of the water, fall • Can happen in the general population • XRAY: if avulsion bone off pubic ramis is < 2cm, referral to Orthopedist • ULTRASOUND: look for amount of avulsion, hematoma • Hamstring avulsion In Skeletally immature athletes avulsion form the apophysis of the ischial tuberosity and can be treated conservatively most often • Rarely require surgical repair/fixation ADDUCTORS: Strain
• Less common injury compared to hamstring injury • Hams>>Adductor>Quad • Adductor injury can be seen with • Breast Stroke • Soccer athletes esp. if they have poor hip ROM • Hockey, speed skating, roller derby, figure skating, XC skiing ADDUCTORS: Strain
• DIFF DX: Sports Hernia/Pubalgia • Look for tenderness over pubic symphysis, distal rectus abdominus, conjoint tenden • XRAY: to rule out avulsion • U/S: to assess muscular integretity • TRMT: PRICES, Stretch, Dry Needling, PRP, PT BONE (FEMUR) ISSUES
• FEMUR • Traumatic/Incidental Fracture • Stress Fracture • Pathologic Fracture BONE (FEMUR) ISSUES
• FEMUR • Traumatic/Incidental Fracture • Open physes • Legg-Calve Perthes • AVN of Epiphyses • Slipped Femoral Capital epiphyses • Salter-Harris • Closed physes • Location, Location, Location BONE (FEMUR) ISSUES
• FEMUR • Stress Fracture • Normal Bone, Abnormal stress • Excessive exercise • Military marching • Abnormal Bone, Normal Stress • Osteoporosis • Chronic corticosteroids • Amenorrhea • Vitamin D deficiency • Osteogenic Imperfecti (COL1A1)
16 yo small wrestler with thigh pain after summer spent “running and cutting weight.” BONE (FEMUR) ISSUES
• FEMUR • Pathologic Fracture • BENIGN • Non-Ossifying Fibroma • Cortical defect • Aneurysmal Bone Cyst • MALIGNANT • Secondary more common than primary tumors • Most primary occur BEFORE age of 30 years old • PRIMARY: Osteosarcoma, SECONDARY: metastasis, Multiple myeloma, Lung CA, Prostate CA Review
• Irrigate abrasions/ lacerations • Compartment syndrome judiciously with WATER • Know the 5 Ps • Small contusion ICE • Perform Compartment pressure testing • ACUTE/TRAUMA/EMERGENANT • Large Contusions /Hematomas • CHRONIC/ Exertional/ Non-emergent • Knee flexion for 24 hours • Assess with U/S • Bone • Traumatic fracture • Quadriceps tendons tears: SURGERY • Open vs closed physeal • Hamstring tears: RARELY need surgery • Stress fracture • Normal Bone, Abnormal stress • Abnormal Bone, normal stress • Pathologic fractures: METS and OS • Others Causes: • PMR, Rhabomyolysis, etc Thank you for your time!