AI Chapter 15

Preventing Injuries

Achilles Tendon Stretching: Tight heel cord may limit dorsiflexion. Should routinely stretch before and after practice. Performed with knee extended and flexed 15-30 degrees. Strength Training: Static and dynamic joint stability is important in preventing injury. Develop a balance in strength throughout the range.

Sprains

Ankle Injuries: Sprains: Single most common injury in athletics caused by sudden inversion or eversion moments. Inversion Sprains: Most common and results in injury to the lateral ligaments. Anterior talofibular ligament is injured with inversion, plantar flexion and internal rotation. MOI: foot is forcefully inverted or occurs when foot comes in contact with uneven surface.

Ankle Special Test

Anterior drawer test: Used to assess anterior talofibular ligament primarily and other lateral ligament secondarily. A positive test occurs when foot slides forward and/or makes a clunking sound as it reaches the end point. Performed to determine extent of inversion or eversion injuries. Talar Tilt Test: Calcaneus is inverted and excessive motion indicates injury to calcaneofibular ligament and possibly the anterior and posterior talofibular ligaments If the calcaneus is everted, the deltoid ligament is tested.

Eversion Ankle Sprains

Bony protection and ligament strength decreases likelihood of injury. Eversion force resulting in damage to deltoid and possibly fx of the fibula. Deltoid can also be impinged and contused with inversion sprains.

Stress Fracture of Tibia or Fibula

Caused: Common overuse condition, particularly in those with structural and biomechanical insufficiencies. Result of repetitive loading during training and conditioning. Signs: Pain with activity Pain more intense after exercise than before Point tenderness; difficult to discern bone and soft tissue pain. Bone scan results (stress fracture vs. periostitis). Care: Eliminate offending activity. Discontinue stress inducing activity 14 days. Use crutch for walking. Weight bearing may return when pain subsides. After pain free for 2 weeks athlete can gradually return to activity. Biomechanics must be addressed.

Shin Contusion

Caused: Direct blow to lower leg (impacting periosteum anteriorly). Signs: Intense pain, rapidly forming hematoma w/ jelly like consistency. Increased warmth. Care: RICE, NSAIDs and analgesics as needed. Maintaining compression for hematoma (which may need to aspirated) Sometimes fit with doughnut pad.

Achilles Tendinitis/Tendinosis

Caused: Inflammatory condition involving tendon. Tendon is overloaded due to extensive stress. Presents with gradual onset and worsens with continued use. Decreased flexibility exacerbates condition. Signs: Generalized pain and stiffness, localized proximal to calcaneal insertion, warmth and painful with palpation, as well as thickened. May progress to morning stiffness. Care: Resistant to quick solutions, must reduce stress, aggressive stretching, anti-inflammatory meds.

Syndesmotic Sprain

Caused: Injury to the distal tibiofemoral joint (anterior/posterior tibiofibular ligament). Torn w/ increased external rotation or dorsiflexion. Injured in conjunction w/ medial and lateral ligaments Care: May require extensive period of time in order to return to play

Ankle Fractures/Dislocations

Caused: Number of mechanisms - often similar to those seen in ankle sprains. Signs: Swelling and pain may be extreme with possible deformity. Care: Splint and refer to physician for X-ray and examination. RICE to control hemorrhaging and swelling. Once swelling is reduced, a walking cast or brace may be applied, w/ immobilization lasting 6-8 weeks. Rehabilitation is similar to that of ankle sprains once range of motion is normal.

Achilles Tendon Rupture

Caused: Occurs w/ sudden stop and go; forceful plantar flexion w/ knee moving into full extension. Commonly seen in athletes > 30 yo. Signs: Sudden snap w/ immediate pain which rapidly subsides. Point tenderness, swelling, discoloration; decreased ROM. Obvious indentation and positive Thompson test. Care: surgical repair for serious injuries. Non-operative treatment consists of RICE, NSAIDs, analgesics, and a NWB cast for 6 weeks to allow for proper tendon healing. Rehab: Regain normal ROM then a gradual and progressive strengthening program.

Compartment Syndrome

Caused: Rare acute traumatic syndrome due to direct blow or excessive exercise. May be classified as acute, acute exertional or chronic. Signs: Excessive swelling compresses muscles, blood supply and nerves. Deep aching pain and tightness is experienced. Weakness with foot and toe extension and occasionally numbness in dorsal region of foot. Care: Severe may need emergency care to reduce fascia, RICE, NSAIDS, surgical release has 2-4 months recover. Conservative management require activity modification, icing, and stretching.

Tibial and Fibular Fracture

Caused: Result of direct blow or indirect trauma. Fibular fractures seen with tibial fractures or as the result of direct trauma. Signs: Pain, swelling, soft tissue insult Leg will appear hard and swollen Deformity may be open or closed. Care: Immediate treatment should include splinting to immobilize and ice, followed by medical referral. Restricted weight bearing for weeks/months depending on severity.

Tendinosis

Caused: Singular cause or collection of mechanisms. Footwear, mechanics, trauma, overuse, limited flexibility. Signs: Pain & inflammation, Crepitus, Pain with AROM & PROM. Care: Rest, NSAIDs, modalities Orthotics for foot mechanic.

Graded Ankle Sprain

Grade 1: Mild pain and disability, weight bearing is apparent, point tenderness over ligaments and no laxity. Grade 2: Moderate where they feel or hear a pop/snap, painful, difficulty weight bearing, tenderness, and edema. Positive Talar Tilt and anterior drawing tests. Grade 3: Severe pain, swelling, bleeding in joint spaces, discoloration, can't bare weight, positive Talar tilt and anterior drawer, instability due to ruptured ligament.

Care for a Sprain

Manage pain and swelling by icing for 20 minutes for every hour over 3 days. RICE. Avoid weight bearing for 24hrs.

Shin Splints

Medial Tibial Stress Syndrome. Caused: Pain in anterior portion of shin. Stress fractures, muscle strains, chronic anterior compartment syndrome, periosteum irritation. Caused by repetitive microtrauma. Includes exertional compartment syndrome. Signs: Diffuse pain about disto-medial aspect of lower leg. As condition worsens ambulation may be painful, morning pain and stiffness may also increase. Can progress to stress fracture if not treated. Care: Get x-ray and bone scan, activity modification, correct abnormal biomechanics, ice massage, arch taping and orthotics.

Functional/Neuromuscular Tests

Neuromuscular: Training on uneven surfaces and balance boards. While weight bearing the following should be performed: Walk on toes (plantar flexion), Walk on heels (dorsiflexion), Hops on injured ankle, Start and stop running, Change direction rapidly, Run figure eights.

Special tests for Lower Leg

Percussion/bump and Compression tests: Used when fracture is suspected. Percussion test is a blow to the tibia, fibula or heel to create vibratory force that resonates w/in fracture causing pain. Compression test involves compression of tibia and fibula either above or below site of concern.

Thomas Test:

Used to assess the integrity of the Achilles tendon. Positive test is identified if the ankle does not plantar flex when muscle belly is squeezed when compared bilaterally.