Untoward Consequences of Sports Injuries James G. Garrick, M.D. Center for Sports Medicine Saint Francis Memorial Hospital San Francisco CA 94010 Ph. 415 353-6407 [email protected]

Knee is the most frequently injured anatomic region in sports

ACL

ACL

• Basketball • Soccer • Volleyball • Gymnastics • Skiing

• Females 3-5X

ACL History

ACL Examination

• Usually non-contact • "Pop" or ”snap” • Sense of "dislocation" or "shift” • Pain - variable

•

more likely to sustain Previously injured more likely to sustain

• Effusion in 12-24 hours • Tenderness • Variable • Posterior-lateral tibial plateau

• Drawer test (+) in 50% • Lachman test (+) in 95%

ACL Examination • Drawer test

ACL Other tests

• X-rays • May be fracture of lateral tibial

ACL Examination • Lachman test

MCL • Football - clipping • Soccer - slide tackle

plateau

• MRI • Not definitive for ACL tear • Will show meniscus pathology • Sub-chondral “bruising”

MCL

MCL History

• Skiing - non-

• Lateral blow (clipping in football) • Valgus/rotation in skiing • Immediate, sharp, medial pain • May disappear with complete tear • Sense of instability

contact

MCL Examination

MCL Examination

• Swelling over ligament • Tenderness over ligament • May be minimal effusion • Laxity with valgus stress in 20° of

• Medial collateral ligament

flexion

MCL Examination

MCL Examination

• Medial collateral

• Flex 20° • Gently “open”

ligament

medial side of knee

MCL Other tests

Patellar Dislocation

• X-rays • To rule out epiphyseal fracture • MRI • Unnecessary

• Females > males • Quadriceps contracting • Foot externally rotated • Knee partially flexed

Patellar Dislocation History

Patellar Dislocation Examination

• Non-contact • “Grinding”, “tearing”, sensation • Immediate disability • Immediate, significant swelling

• Significant effusion • Medial ecchymosis (if > 24 hours) • Tender (4+) medial retinaculum • Positive patellar apprehension test

Patellar Dislocation Examination

Patellar Dislocation Other tests

• Patellar apprehension test • Partially flexed knee • Gently move patella laterally

• X- rays • To rule out intra-articular fracture • Aspiration • Fat floating on blood = fracture

Meniscus Tears (youth)

Meniscus Tears (youth)

• Medial • Cutting/turning • Weight-bearing

• Lateral • Weight-bearing • Flexed/ hyperflexed knee

Meniscus Tears (“Mature”)

Meniscus Tears History

• May be minimal trauma • Arising from sitting • Getting out of car • Mis-step when running/walking

• Memorable incident (youth) • “Pop” or “snap” • Sudden loss of motion (if fragment

Meniscus Tears Examination

Meniscus Tears Examination

• “Locked” - unable to fully extend • Pain over site of tear (medial or

• Tender medial

lateral) • May (often) have tear without locking

displaced) • Medial or lateral pain

joint line

• Examine with knee flexed 90°

• Tenderness at joint line • Effusion - usually within 24 hours

Meniscus Tears Examination

Meniscus Tears Other Tests

• Tender lateral

• X-rays - No value • MRI • Definitive

•

joint line Examine in “figure 4” position

Injuries

Encourage Sports and Fitness Activities

• Little evidence that rate of injury is either increasing or decreasing • Increasing number of injuries simply because of increased number of participants

• Benefits for: • Obesity • Cardiovascular disease • Diabetes • Osteoporosis • Depression.

Encourage Sports and Fitness Activities

Tapper and Hoover, Late Results after Meniscectomy. JBJS (Am) 1969;51(3):517-26)

• Participation requires a reasonably intact

• 68% with “satisfactory” clinical

•

musculo-skeletal system Problems:

• Overcome the residuals of previous “sports injuries”

• Overcome the residuals of previous sports/fitness participation

• Deal with injuries arising from future

results • Only 45% of men and 10% of women had “symptom-free” knees • Those with meniscectomy at < 20 years of age had the smallest % of good to excellent results (StatSig)

fitness activities

Higuchi et al, Factors Affecting LongTerm Results after Arthroscopic Partial Meniscectomy. CORR 1000;(377):161-8.

Long(er) Term Follow-Up Knee problems

• 67 Isolated Meniscectomies • Average F/U 12.2 years -79% had

• Following meniscectomy, at 10 years

“satisfactory” functional outcome • 48% showed “osteoarthritis deterioration”

at least 50% will show some X-ray evidence of joint deterioration

Gillquist and Messner, Anterior Cruciate Ligament Reconstruction and the Long Term Incidence of Gonarthrosis. SportsMed 1999; 27(3), 143-156)

Gillquist and Messner, Anterior Cruciate Ligament Reconstruction and the Long Term Incidence of Gonarthrosis. SportsMed 1999; 27(3), 143-156)

• Meniscectomy (intact ligaments) -

• Arthritis changes occur more rapidly with

30-40% gonarthrosis • Complete ACL rupture (with or without associated injuries) - 50-70% gonarthrosis

•

• 70% if associated with meniscus rupture or tear of collateral ligaments

Public Health Consequences of Injuries

greater age at time of either ACL or meniscus injury “…no association has been found between the degree of instability after injury or the stability achieved by operation and the risk to develop arthrosis”.

The Role of Musculoskeletal Injuries on Subsequent Injuries • Subsequent injuries among those with

• Average age at time of meniscectomy •

< 40 years Average age at time of ACL injury < 30 years

reconstructed ACL (annual risk)

• Shipiro -@ 58 months - 2% risk of same side injury, 1% contralateral

• Shelbourne @ 4.4 years - 0.5% re-injury • Jomha @ 7 years - 0.7% re-tears, 1.2% •

The Role of Musculoskeletal Injuries on Subsequent Injuries

• ACL annual incidence • Previously uninjured - 1/3000 • Previous ACL reconstruction - 1/50 • Same incidence in previously uninjured women in basketball or soccer - Sports with the highest ACL injury rates

contralateral Oats @ 3 years (skiers) - 2.2% re-injury, 0.7% contralateral

Retrospective Studies

• Framingham Study • Physical activity increased the risk of osteoarthritis of the knee -Odds ratio = 3.3 among those in the highest quartile (most active)

Retrospective Studies

Retrospective Studies

• Lane et al (UCSF study) • 5818 elderly women - odds ratio among

• Sandmark, et al • Swedish men and women with TKA for

those in the highest quartile for all physical activity performed as teenagers:

osteoarthritis -

• “Highly exposed to sports” - Odds ratio 2.9

• Symptomatic osteoarthritis of the hip - 2.0 • Severe radiographic evidence of hip osteoarthritis - 1.7

Rationale for Encouragement of Sports & Fitness Activities

45 y/o Male with Grade II Osteoarthritis of the Knee

• Children becoming more sedentary • Older segment of population fastest

• “Avoid or minimize activities such as soccer, basketball, distance running”

growing • Older segment expecting to be more active

14 y/o Female with Successfully Reconstructed ACL

• If she returns to soccer and plays through college:

14 y/o Female with Successfully Reconstructed ACL

• Should we: • 1. Encourage her to continue in

• Her risk of sustaining another ACL injury (same or opposite side) is 25% • Her risk of having X-Ray evidence of gonarthrosis before the age of 25 is >50%

• 2.

soccer Encourage her to find another sport with a lower ACL injury rate and less impact loading

Need to Know:

Our Responsibilities

• What are the additional risk factors

• Be a technician and “fix” the injury

associated with post-injury osteoarthrosis?

• Is the osteoarthrosis, in part, a result of continuing high levels of sports participation?

allowing a return to participation • Learn enough that we might provide advice aimed at minimizing the longterm consequences of the injury

Our Responsibilities

Our Responsibilities

• Examine the long-term (>20 years)

• Provide strategies to prevent injuries • Treat injuries • Minimize future problems

consequences of common injuries

• Following an injury (Ex. ACL or meniscus), why do some NOT develop osteoarthritis?

Sports Experience and Sports Injuries • Re. Long-term musculo-skeletal problems:

• There is no evidence that with the more successful acute management of sports injuries there is less likelihood of longterm consequences (osteoaarthritis) • There is evidence that continued participation (especially at high levels) will result in more problems