Year : 2018 | Volume
: 15 | Issue : 2 | Page : 79--87
A review of sports-related injuries: Head to toe spectrum
Reddy Ravikanth1, Jyotin Kshitiz Singh2, Anegh Pavithran3, Anoop Pilar4, Anush Nagotu5, Parthasarathi Sarkar6, S Sandeep6, Denver Steven Pinto1, Mathew David4, John Joshy7, Manu Jacob Abraham4, Ashok Alapati4, Robert Patrick Selvam8, Sunil Mathew9,
1 Department of Radiology, Malabar Medical College, Kozhikode, Kerala, India
2 Department of General Medicine, Ministry of Health Holdings, Singapore
3 Department of Oral and Maxillofacial Surgery, Sree Anjaneya Institute of Dental Sciences, Kozhikode, Kerala, India
4 Department of Orthopedics, St. John's Medical College, Bengaluru, Karnataka, India
5 Department of General Surgery, Wayanad Institute of Medical Sciences, Wayanad, Kerala, India
6 Department of Radiology, St. John's Medical College, Bengaluru, Karnataka, India
7 Department of Emergency Medicine, Malabar Medical College, Kozhikode, Kerala, India
8 Department of Pathology, St. John's Medical College, Bengaluru, Karnataka, India
9 Department of Anatomy, St. John's Medical College, Bengaluru, Karnataka, India
Department of Radiology, Malabar Medical College, Kozhikode - 673 315, Kerala
All sports come with a risk of injury, and in general, the more contact involved in the sports, the higher the risk of a more significant or traumatic injury. The most frequent types of sports injuries are sprains (ligament injuries), strains (muscle injuries), and stress fractures (bone injuries). In sports medicine, a catastrophic injury is defined as severe trauma to the human head, spine, or brain. Concussions in sports became a major issue in the 2000s as evidence connected repeated concussions and subconcussive hits with chronic traumatic encephalopathy and increased suicide risk. Overuse and repetitive stress injury problems associated with sports include jumper's knee, tennis elbow, and tendinosis. In this review article, we have made an attempt to describe the head to toe spectrum of sports-related injuries including traumatic injuries of the head and face, extremity injuries, soft-tissue injuries, and contact sports-related injuries.
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Ravikanth R, Singh JK, Pavithran A, Pilar A, Nagotu A, Sarkar P, Sandeep S, Pinto DS, David M, Joshy J, Abraham MJ, Alapati A, Selvam RP, Mathew S. A review of sports-related injuries: Head to toe spectrum.Apollo Med 2018;15:79-87
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Ravikanth R, Singh JK, Pavithran A, Pilar A, Nagotu A, Sarkar P, Sandeep S, Pinto DS, David M, Joshy J, Abraham MJ, Alapati A, Selvam RP, Mathew S. A review of sports-related injuries: Head to toe spectrum. Apollo Med [serial online] 2018 [cited 2022 Dec 3 ];15:79-87
Available from: https://apollomedicine.org/text.asp?2018/15/2/79/236001
The physical, mental, and emotional development associated with athletic endeavors can play a great dividend in adulthood. Unfortunately, on the flipside of many athletic endeavors is the risk of injury, which can bring long-term consequences. Sports injuries generally occur for two different reasons: trauma and overuse. Overuse, acute sprain, and strain injuries are the most common. An overuse injury results from excessive wear and tear on the body, especially in the areas subject to repeated activity. Sports-related injuries are the leading cause of emergency room visits in children, teens, and adolescents. In this review article, we have made an attempt to describe the head to toe spectrum of sports-related injuries, including traumatic injuries of the head and face, extremity injuries, soft-tissue injuries, and contact sports-related injuries.
Various Sports-Related Injuries
A concussion can be defined as an injury to the brain, due to a blow to the head where the brain is jarred or shaken. Concussions are serious injuries that should not be taken lightly. An athlete who experiences a concussion should seek out a certified athletic trainer or a physician with experience treating concussions. Common concussion symptoms can include headache, confusion, dizziness, nausea and/or vomiting, slurred speech, sensitivity to light, and delayed response to questions.
Sports-related head injuries include acute subdural hematoma (ASDH), concussion, and chronic traumatic encephalopathy (CTE). Sports-related ASDH is a leading cause of death and severe morbidity in popular contact sports such as American football in the USA and judo in Japan. It is thought that rotational acceleration is most likely to produce not only cerebral concussion but also ASDH due to the rupture of a parasagittal bridging vein, depending on the severity of the rotational acceleration injury. Repeated sports head injuries increase the risk for future concussion, cerebral swelling, ASDH, or CTE. Severe sports-related head injuries include ASDH, acute epidural hematoma, cerebral contusion, traumatic cerebrovascular accidents, diffuse brain swelling, diffuse axonal injury, and skull fractures. Among them, ASDH is a leading cause of death and severe morbidity in general and in American football, judo, boxing, and snowboarding in particular.
Face-related traumatic injuries
Dental injuries are the most common type of orofacial injury sustained during participation in sports with the increased popularity of contact sports and encouragement to participate at an early age. The common orofacial sports-related injuries include soft-tissue injury and hard-tissue injury that includes those to the teeth and facial bones, such as tooth intrusions, luxation, crown and/or root fractures, complete avulsions, dental facial fractures, abrasions, contusions, and lacerations. Among the dental injuries, tooth intrusion is the most severe form of displacement injury. Tooth extrusion, crown, root fractures, and tooth avulsion are some common sports-related dental injuries encountered.
Facial fractures and temporomandibular joint injuries
Zygomatic bone is the most frequent site of injury. Fractures of the zygoma account for approximately 10% of the maxillofacial fractures seen in sports injuries, occurring as a result of direct blunt trauma from a fall, elbow, or fist. Due to prominent shape and projection of the mandible, it is frequently fractured in trauma. In mild and severe trauma, the condylar processes can be forced posteriorly resulting in temporomandibular dislocation and acute malocclusion.
Sports-related cervical spine injuries
Serious cervical injury is reported to occur as a result of axial load or a large compressive force on the head. This mechanism carries a higher associated risk of injury when the neck is slightly flexed (approximately 30°), due to the spine being brought out of its normal lordotic alignment and configuration on impact. The result is the improper force distribution to the thorax; the cervical spine is placed in a straight line due to flexion with the supporting musculature and soft tissues unable to cope with absorbing the force. This then manifests in “pinching” of the spinal cord with spinal cord neuropraxia ensuing. Such an acceleration–deceleration injury is usually secondary to high-velocity collisions between players, with acceleration usually causing a whiplash (type of extension force) and deceleration resulting due to flexion forces. Compression of the cervical spine between the body and a rapidly decelerating head is a primary cause of cervical fracture, dislocation, and quadriplegia. When the impact force is greater than the yield strength of the vertebrae, a fracture is likely with or without dislocation. Neurologic damage can occur with the presence of a fracture, bone fragments, or herniated disc contents that encroach of the spinal cord.
Shoulder injuries cover a large number of sports injuries from dislocations, misalignment, strains on muscles, and sprains of ligaments.
Rotator cuff tendonitis/tendinosis/bursitis
Tendonitis, tendonosis, and bursitis are three separate clinical entities, for which the names are often incorrectly used interchangeably. Tendonitis is inflammation of the tendon. In many cases, it is actually the tendon sheath that is inflamed and not the tendon itself. Bursitis is an inflammation of the subacromial bursa. Tendonosis implies intratendinous disease, such as intrasubstance degeneration or tearing. Tendonitis/tendonosis is most frequently an overuse injury in the overhead athlete and does not usually represent an acute injury process.
Joint dislocations frequently stem from a person falling or receiving an impact while his arm is outstretched. The shoulder is a very mobile and therefore unstable joint. It is the most dislocated joint in the body. The humeral head is almost always displaced anteriorly and medially below the coracoid process. The shoulder almost always dislocates to anterior and inferior because motion to superior is limited by the acromion, coracoid process, and rotator cuff. Posterior dislocations are uncommon and easily missed because there is less displacement compared to the anterior dislocation. On the anteroposterior view, the head looks strange due to the internal rotation. On the transscapular-Y view, the humeral head is displaced posteriorly. Sometimes, the displacement is difficult to appreciate, especially when the transscapular-Y view is slightly rotated.
Rotator cuff injuries
Muscles of the rotator cuff are active during various phases of the throwing motion. During the late cocking and early acceleration phases, the arm is maximally externally rotated, potentially placing the rotator cuff in position to impinge between the humeral head and the posterior superior glenoid. Known as “internal impingement” or “posterior impingement,” this may place the rotator cuff at risk for undersurface tearing (articular sided). Conversely, in the deceleration phase of throwing, the rotator cuff experiences extreme tensile loads during its eccentric action, which may lead to injury. Rotator cuff tears in the overhead athlete may be of partial or full thickness. The history of shoulder pain either at the top of the wind-up (acceleration) or during the deceleration phase of throwing should alert the examiner to a rotator cuff source of pain or loss of function. Rotator cuff tears may be caused by primary tensile cuff disease (PTCD), primary compressive cuff disease (PCCD), or internal impingement. PTCD results from the large, repetitive loads placed on the rotator cuff as it acts to decelerate the shoulder during the deceleration phase of throwing in the stable shoulder. The injury is seen as a partial undersurface tear of the supraspinatus or infraspinatus. PCCD is found on the bursal surface of the rotator cuff in throwers with stable shoulders. This process occurs secondary to the inability of the rotator cuff to produce sufficient adduction torque and inferior force during the deceleration phase of throwing.
Labrum is the ring of socket around the glenoid. This is the site of attachment of the biceps tendon as well as the stabilizing ligaments of the shoulder. Labral tear symptoms are frequently vague and challenging to diagnose. A labral tear causes pain, often deep in the shoulder. Labral tears can be associated with a clicking sound, with movement, and athletes may be unable to throw or hit with their usual speed or strength. There are two types of labral tears: SLAP tears and Bankart lesions. SLAP is an acronym that stands for “superior labral tear from anterior to posterior.” SLAP starts at the 12 o'clock position where the biceps anchor is located, which tears the labrum off the glenoid. SLAP typically extends from the 10 o'clock position to the 2 o'clock position but can extend more posteriorly or anteriorly and even extend into the biceps tendon. Bankart lesions are typically located in the 3–6 o'clock position because that's where the humeral head dislocates.
Acromioclavicular joint sprain
The acromioclavicular (AC) joint links the acromion of the scapula to the clavicle. Sprains frequently occur when someone falls on his shoulder with the arm at the side or receives an impact on the top of the shoulder. Common causes include being checked into the boards in hockey, tackled in rugby, being pitched over a bicycle's handlebars, and falling. Features of AC joint injury include soft-tissue swelling/stranding, widening of the AC joint, increased coracoclavicular distance, and superior displacement of the distal clavicle.
A clavicle fracture produces symptoms that typically include pain at the site of the break and a decreased ability to move the affected arm. Complications can include pneumothorax and injury to the nerves or blood vessels in the area. Incidents that may lead to a clavicle fracture include automobile accidents, biking accidents (especially common in mountain biking), horizontal falls on the shoulder joint, or contact sports such as football, rugby, hurling, or wrestling. It is often caused by a fall onto a shoulder, outstretched arm, or direct trauma. The junction of the medial two-third and lateral one-third of the clavicle is most often involved. Diagnosis is typically based on symptoms and confirmed with X-rays. Clavicle fractures are typically treated by putting the arm in a sling for 1 or 2 weeks.
Medial epicondylitis is an inflammatory condition around the common flexor tendon of the elbow. It is less common than lateral epicondylitis. This repetitive stress and overuse can lead to tendinosis involving the musculotendinous junction of the flexor pronator muscle group at the medial elbow, with microtrauma and partial tearing that may progress to a full-thickness tendon tear. Described features on magnetic resonance imaging (MRI) include thickening and increased signal intensity on both T1- and T2-weighted sequences of the common flexor tendon and soft-tissue edema around the common flexor tendon.
Lateral epicondylitis, also known as “tennis elbow,” is an overuse syndrome of the common extensor tendon and predominantly affects the extensor carpi radialis brevis tendon. Lateral epicondylitis occurs with a frequency seven to ten times that of medial epicondylitis. A history of tennis playing or similar racket sports is sometimes elicited, but the condition often results from other repetitive athletic or occupational activities or without an identifiable cause. Repetitive stress and overuse lead to tendinosis involving the origin of the extensor tendons at the lateral elbow, with microtrauma and partial tearing that may progress to a full-thickness tendon tear. Alternatively, it may also result from direct trauma. On plain radiograph, up to 25% of the patients with lateral epicondylitis may have calcification within the soft tissue around the lateral epicondyle. On MRI, the best diagnostic clue for diagnosis of lateral epicondylitis is abnormal thickening and increased signal intensity within the common extensor origin from the lateral epicondyle.
Chronic injury to ulnar collateral ligament (UCL) of the thumb was first described in Scottish gamekeepers who used to kill hunted rabbits by breaking their necks with their thumbs and index fingers. Acute injury called “skier's thumb” is now more common among skiers due to fall on outstretched hand with abducted thumb caught in the pole strap. It may comprise up to 50% of the injuries to hand in skiers. This may also be seen in rheumatoid arthritis. Injury results in disruption of the UCL at its site of insertion on the metacarpal–phalangeal joint of the thumb. UCL is a short ligament that originates from the metacarpal head and inserts into medial aspect and base of proximal phalanx of the thumb. Often, it is associated with a fracture of the base of the proximal phalanx. Stener lesions are seen in the context of a torn ulnar collateral ligament of the thumb's metacarpophalangeal joint. Distal portion of the ligament retracts and points superficially and proximally. Plain radiograph is almost always the first examination and is often able to give the diagnosis. If a small avulsion fracture is present, then this will be seen at the ulnar corner of the base of the proximal phalanx. MRI is increasingly used to asses X-ray occult injuries to the ulnar collateral or to attempt to identify a Stener lesion. Findings include discontinuity of the ligament ± joint capsule, bone marrow edema, fracture, and Stener lesion.
Sports-related fractures and dislocations
Football, rugby, and skiing account for majority of fractures. The most common fractures are noted in the finger phalanges, distal radius, and ulna and metacarpal bones. Sports-related fractures are common in adolescents, particularly in males. They tend to be low-energy injuries affecting the upper limb in particular. Few require operative treatment although their frequency means that they impose significant demands on orthopedic surgeons and health systems.
Piriformis syndrome is a neuromuscular condition characterized by hip and buttock pain. This syndrome is often overlooked in clinical settings because its presentation may be similar to that of lumbar radiculopathy, primary sacral dysfunction, or innominate dysfunction. The ability to recognize piriformis syndrome requires an understanding of the structure and function of the piriformis muscle and its relationship to the sciatic nerve. Piriformis syndrome is a peripheral neuritis of the sciatic nerve caused by an abnormal condition of the piriformis muscle. It frequently goes unrecognized or is misdiagnosed in clinical settings. Piriformis syndrome can “masquerade” as other common somatic dysfunctions, such as intervertebral discitis, lumbar radiculopathy, primary sacral dysfunction, sacroiliitis, sciatica, and trochanteric bursitis. Delay in diagnosing piriformis syndrome may lead to pathologic conditions of the sciatic nerve, chronic somatic dysfunction, and compensatory changes resulting in pain, paresthesia, hyperesthesia, and muscle weakness. The challenge for physicians is to recognize symptoms and signs that are unique to piriformis syndrome, enabling appropriate treatment in a timely manner.
Athletic pubalgia refers to pain around the pubic symphysis and can have different causes, including what has become known as sports hernia or sportsperson's hernia and osteitis pubis. Athletic pubalgia is a clinical syndrome of chronic lower pelvic and groin pain, usually encountered in athletes. It is either a musculotendinous or osseous injury that involves the insertion of abdominal muscles on the pubis and the upper aponeurotic insertion of the adductor muscles. Although it can occur following an acute injury, it is most often the result of repeated microtrauma. Athletic pubalgia can only be diagnosed on MRI, and findings are usually very subtle. The most specific finding is a hyperintense T2-weighted image (T2WI) signal involving the anteroinferior aspect of the pubic symphysis. Other findings include osteitis pubis, which can also be appreciated on computed tomography, tenoperiosteal disruption of the aponeurosis or frank tear, and marrow edema at the pubic tubercle. Differential diagnoses include piriformis syndrome, hip adductor injury, and pelvic stress or insufficiency fracture.
Groin injuries make up 2%–5% of all sports-induced injuries, of which adductor strain is the usual musculoskeletal etiology of the pain. The arrangement and fusion of adductor muscles, their fibrocartilaginous enthuses, and differences in vascularity of their proximal tendons may be important anatomical considerations in the pathogenesis and pattern of adductor-related groin pain. The adductor longus is a commonly injured muscle in sport activities. The adductor tendons have a small insertion area that attaches to the periosteum-free bone. This transitional zone is characterized by a poor blood supply and rich nerve supply, which is the cause of high level of perceived pain and poor healing in adductor strains.
The transition from rest to intensive physical activity can cause pathological changes in various organs, particularly in the urinary tract. Hematuria (microscopic or macroscopic) is one of the abnormalities commonly found after sports activity. This phenomenon can occur in noncontact sports (such as rowing, running and swimming) as well as in contact sports (boxing and football). The pathophysiology can be either traumatic or nontraumatic. Renal trauma and/or bladder injury due to repeated impact of the posterior bladder wall against the bladder base can cause vascular lesions and consequently hematuria. There are two mechanisms of nontraumatic injury. (1) Vasoconstriction of the splanchnic and renal vessels occurs during exercise in order that blood can be redistributed to the contracting skeletal muscles, thus causing hypoxic damage to the nephron. This results in increased glomerular permeability which would favor increased excretion of erythrocytes and protein into the urine. (2) A relatively more marked constriction of the efferent glomerular arteriole results in an increased filtration pressure, which favors increased excretion of protein and red blood cells into the urine. Sports hematuria usually has a benign self-limited course. However, coexisting urinary tract pathological conditions should be excluded carefully.
Postexercise proteinuria (PEP) may be related to the loss of glomerular wall-negative charge, relative preservation of glomerular filtration despite decreased renal blood flow with resultant increased capillary permeability, proteinuria out of proportion of maximal tubular reabsorption capacity following heavy exercise, and hypoxia and oxidative stress produced by free radicals owing to enhanced oxygen consumption in muscles. PEP can present either with glomerular or glomerulotubular (mixed) patterns. It is suggested that the sympathetic stimulation, decreased renal blood flow, increased filtration fraction, and glomerular permeability alterations during strenuous exercise can lead to glomerular proteinuria, while tubular proteinuria results from partial tubular reabsorption inhibition. The pattern of PEP depends on the exercise intensity rather than its duration so that light and moderate exercises are preponderantly accompanied by glomerular proteinuria and heavy exercise is associated with mixed proteinuria.
Weightlifting is considered as a dynamic strengthen exercise and power sport in which the athletes lifts a maximum weight with one repetition. The weightlifting as other sports has common musculoskeletal injuries in different body locations corresponding to the sports beneficial. However, identifying the injuries incidence and the etiology is a first two-step in the model of the injury prevention to introduce preventive measures for sports. Therefore, this literature review is aimed to focus on the incidence and the etiology related to injuries of the weightlifting. However, studies on the incidence injuries revealed that the children have more injuries related to accident than the adults, whereas the adults have more injuries related to strain and sprain. The most common injured locations are shoulder, lumbar spine, knee, elbow, hand, and wrist in the weightlifters. The percentage of the injuries according to the location is shoulder (36%), lumbar spine (24%), elbow (11%), and knee (9%).
There are many causes of low back pain. Here, we discuss the most common causes in athletes: musculoligamentous strain, spondylolysis, spondylolisthesis, and herniated nucleus pulposus.
Musculoligamentous strains are probably the most common sports injury. These injuries are diagnosed by exclusion. These injuries are usually self-limiting. Treatment generally focuses on education and prevention of future strains, through proper conditioning, warm-up, and changes in the way an activity are carried out.
Spondylolysis and spondylolisthesis
Spondylolysis is due to defect in pars interarticularis. It is thought that spondylolysis appears in younger and older adults as the result of excessive stress to the spine and eventual stress fractures. In athletes, spondylolysis is most commonly found in those who participate in sports that have frequent hyperextension of the lumbar spine, such as gymnastics, pole vaulting, and football. Weightlifters also have a higher incidence of the disorder due to excessive stress on the spine. Spondylolysis does not always produce noticeable symptoms. When it does, chronic low back pain is the most common symptom. The pain can stem from mechanical (structural) or compressive (pressure on nerves). Initially, conservative treatment is generally suggested.
Herniated nucleus pulposus
A herniated disc occurs when pressure to a disc's outer fibers (annulus) is so great that it rips, and the nucleus ruptures out of its normal space. If it rips near the spinal canal, the bulging disc can push out of its space and into the spinal canal, placing inappropriate pressure on the spinal cord and nerve roots. If a disc bulges a lot or fragments into pieces that lie in the canal, then irritation of the nerves can be severe. The adolescent athlete may also suffer from low back pain that is caused by growth-related problems such as scoliosis and Scheuermann's kyphosis. Scheuermann's kyphosis is a developmental type of kyphosis. The vertebrae are normally rectangular and stacked on the top of one another as building blocks with a soft cushion (disc) in between each one. If they wedge closer together in a triangular shape, as with Scheuermann's kyphosis, it causes the spine to curve more than normal. Sometimes, this deformity is described as “round-back posture” or “hunch-back.”
Retrolisthesis is the posterior displacement of one vertebral body with respect to the adjacent vertebrae, to a degree less than a dislocation. It is associated with increased by a degree and thus impaired function of the spine. It is correlated with a reduction in lumbar lordosis, end-plate inclination, and segmental height. Retrolisthesis hyperloads at least one disc and puts shearing forces of the anterior longitudinal ligament, annular rings, nucleus pulposus, and cartilage end-plate ligament.
Femoroacetabular impingement in athletes
Femoroacetabular impingement (FAI), also known as hip impingement, is increasingly recognized as a common, and possibly often overlooked, etiology of hip pain in athletes. FAI is characterized by the abutment of the acetabular rim and the proximal femur, which may occur by two mechanisms known as “cam” or “pincer” impingement, although most commonly by a combination of the two. It affects athletes at a young age causing significant pain and disruption to athletic performance and activities of daily living. It injures the labrum and articular cartilage and can lead to early osteoarthritis of the hip if left untreated. Cam and pincer mechanisms have been suggested, which may occur together or in isolation. Cam-type impingement is primarily an abnormality of the femoral head–neck junction, whereas the pincer type is principally an abnormality of the acetabulum causing impingement against the femoral neck. Both these subtypes vary slightly in their pathological consequences, but both have been shown to cause cartilage delamination, labral tears and have been linked to early osteoarthritis of the hip.
Hip flexor strain
The two main muscles involved in this group are the iliopsoas and the rectus femoris. Tears to the hip flexors can range from a small partial tear where there are minimal pain and minimal loss of function to a complete rupture involving a sudden episode of severe pain and significant disability. Hip flexor strains range from Grade 1 to Grade 3 and are classified as follows: Grade 1 tear: a small number of fibers are torn resulting in some pain, but allowing full function; Grade 2 tear: a significant number of fibers are torn with moderate loss of function; Grade 3 tear: all muscle fibers are ruptured resulting in major loss of function. The majority of hip flexor strains are Grade 2.
Sciatica is pain, tingling, or numbness produced by an irritation of the nerve roots that lead to the sciatic nerve. The sciatic nerve is formed by the nerve roots coming out of the spinal cord into the lower back. It goes down through the buttock, and then its branches extend down the back of the leg to the ankle and foot. The most frequent cause is a herniating lumbar disc pressing on the neural roots. Extraspinal causes of sciatic pain are usually overlooked because they are extremely rare and due to intraspinal causes (lumbar spinal stenosis, facet joint osteoarthritis, fracture, and tumors of the spinal cord and spinal column) being the main consideration. In rare cases, sciatica can also be caused by conditions that do not involve the spine, such as tumors or pregnancy. The affected skeletal muscles of the left gluteal region and left thigh show decreased girth as well as increased signal in T1- and fluid-sensitive sequences. These muscles show evident postcontrast enhancement as well.
The hamstring group of muscles, located on the back of the upper leg, is a group of three separate muscles and comprises biceps femoris, semimembranosus, and semitendinosus. Hamstring strains are most common among sports that require a high degree of speed, power, and agility such as soccer, basketball, tennis, and football. The typical presentation of a hamstring strain or tear is the acute onset of pain during rapid acceleration or stretching. An audible pop often accompanies the injury. In more severe injuries, ecchymoses and swelling may be visible, and a palpable defect may be felt. Pain is elicited with passive extension of the knee with the hip flexed to 90° and also with resisted knee flexion. Because of the proximity of the sciatic nerve, temporary sciatica or even a sciatic neuropathy may be encountered. MRI reliably depicts the location and extent of hamstring injuries. Fluid-sensitive sequences such as proton-density and T2-weighted fat-suppressed sequences or short-tau inversion–recovery sequences depict tendon tears and avulsions as fluid-signal filled defects at the site of disruption. Adjacent hemorrhage and edema are readily apparent. The multiplanar capabilities of MRI enable a detailed depiction of the muscles or tendons involved. Avulsions at the bone–tendon interface may occur with or without fracture avulsions from the ischial tuberosity. Bony avulsions are most common in adolescents with incomplete fusion of the ischial tuberosity apophysis. These injuries are typically treated conservatively if there is <2 cm distraction at the fracture.
Anterior cruciate ligament tears
The anterior cruciate ligament (ACL) is the most commonly disrupted ligament of the knee, especially in athletes who participate in sports that involve rapid starting, stopping, and pivoting (e.g., soccer, basketball, tennis, netball, and snow skiing). On MRI, imaging of ACL tears should be divided into primary and secondary signs. Primary signs are joint swelling, increased signal on T2 or (Proton-Density Fat-Sat) PD FS, fiber discontinuity, and change in the expected course of ACL referring to ACL angle that is less steep than Blumensaat's line. Secondary signs include bone contusion in the lateral femoral condyle and posterolateral tibial plateau, >7 mm of anterior tibial translation also known as anterior tibial translocation sign or anterior drawer sign, uncovered posterior horn of the lateral meniscus, Segond fracture, and to a lesser degree arcuate sign, reduced posterior cruciate ligament (PCL) angle due to buckling of PCL, positive PCL line, medial collateral ligament (MCL), or ACL injury.
Posterolateral corner injury of the knee
Posterolateral corner (PLC) injuries of the knee are injuries to a complex area formed by the interaction of multiple structures. Injuries to the PLC can be debilitating to the person and require recognition and treatment to avoid long-term consequences. PLC injury of the knee can occur in isolation or with other internal derangements of the knee, particularly cruciate ligament injuries. The importance of injuries to the posterolateral ligamentous complex lies in the possible long-term joint instability and cruciate graft failure if these are not identified and treated. The four main structures are lateral (fibular) collateral ligament, popliteus muscle, popliteofibular ligament, and biceps femoris tendon.
Patellofemoral pain syndrome
Patellofemoral pain syndrome (PFPS) is a spectrum of processes characterized by retropatellar pain (behind the knee cap) or peripatellar pain (around the knee cap) arising from overuse and overload of the patellofemoral joint or biomechanical changes in this joint. PFPS is a term for variety of pathologies or anatomical abnormalities, leading to a type of anterior knee pain. The pain may be caused by increased subchondral bone stress attributed to the stress of articulation or from cartilaginous lesions on the patella or distal femur. It is constituted by a variety of symptoms that include retropatellar pain that is frequently aggravated by sitting (movie sign), stair climbing, and vigorous activity. Complaints of crepitus, effusions, a sense of insecurity, or giving away are reported, and some patients also complain of intermittent catching while extending the knee.
O'Donoghue unhappy triad often occurs in contact sports, such as basketball, football, or rugby, when there is a lateral force applied to the knee while the foot is fixated on the ground. This produces the “pivot shift” mechanism. The O'Donoghue unhappy triad comprises three types of soft-tissue injury that frequently tend to occur simultaneously in knee injuries. O'Donoghue described the injuries as ACL tear, MCL tear/sprain, and medial meniscal tear (lateral compartment bone bruise).
Medial meniscal injuries usually occur when an athlete is attempting to sudden rotation with a fixed foot. Damage results when rotational forces are applied to the knee while it is partially flexed with the foot on the ground. Lateral meniscal injuries are seen with less frequency than medial meniscal injuries. The lateral meniscus permits greater anatomic mobility and is thus less susceptible to tears. Damage to the lateral meniscus can occur when both rotational and compressive forces are applied to the knee while it is fully flexed with the foot fixed on the ground. A combination of torsional and axial loading appears to underlie many meniscal injuries. If intrinsic degeneration of the meniscus is present, minimal trauma may cause tearing. Meniscal degeneration predisposes to meniscal tears. Meniscal injuries are common in the ACL-deficient knee, as a result of abnormal tibial translation. Lateral meniscal injury is usually associated with an acute ACL tear, whereas medial meniscal tears occur more often in persons with chronic ACL insufficiency.
Jumper's knee and Sinding–Larsen–Johansson disease
Jumper's knee is the label often applied to patellar tendinosis, an overuse injury that occurs at the attachment of the patella tendon/ligament to the inferior pole of the patella. The result of repetitive mechanical overload, patellar tendinosis (tendinopathy) demonstrates mucoid degeneration, fibrosis, and neovascularization at pathology. Jumper's knee affects teenage and young adult athletes who are skeletally mature and participate in sports that require frequent jumping and similar activities. MRI demonstrates increased focal T2 signal and swelling of the proximal portion of the patellar ligament, often with edema in the adjacent bone and fat. Findings are most prominent in the posterior portion of the ligament and may be accompanied by small partial tears. At ultrasound, the tendon will be thickened and heterogeneously hypoechoic with increased flow. The normal fibrillar pattern will be disrupted. Sinding–Larsen–Johansson disease is analogous to jumper's knee but occurs in skeletally immature athletes.
Transient lateral patellar dislocation–relocation
Patellar dislocation and relocation typically occurs suddenly after trauma or torsional stress on the extensor mechanism. Clinical evaluation after patellar dislocation/relocation usually reveals a swollen knee that is difficult to examine. Radiographs may show hemarthrosis, and a minority of patients will have a chip fracture of the patella. Transient patellar dislocations are commonly associated with bony contusions or osteochondral fractures involving the medial facet of patella or lateral femoral condyle. The marrow edema and medial patellofemoral ligament injury pattern above are virtually pathognomonic of a transient lateral patellar dislocation. Bone bruises at the anterolateral aspect of the lateral femoral condyle and at the inferomedial patella are the most constant findings in patients who have sustained a recent patellar dislocation. Osteochondral injuries of the inferomedial patella are seen in up to 70% of patellofemoral dislocations. Osteochondral injuries to the inferomedial patella may be the result of impaction during dislocation or shearing with reduction. Femoral osteochondral injuries, when present, typically involve the lateral weight-bearing surface. In either case, careful search for possible displaced osteochondral fragments is necessary as surgery is often indicated in such patients.
Lipoma arborescens (LA) is a rare disorder characterized by villous lipomatous proliferation of the synovial tissue. This condition is more common in men than in women, and most affected patients are in the fifth to sixth decades of life. It is usually monoarticular, occurring most frequently in the knee, particularly in the suprapatellar pouch. MRI is the investigation of choice and synovectomy appears to be curative. The differential diagnosis includes pigmented villonodular synovitis, synovial lipoma, synovial chondromatosis, rheumatoid arthritis, synovial hemangioma, amyloid arthropathy, and xanthomata. Pigmented villonodular synovitis has a low intensity on T1-weighted image (T1WI) and T2WI due to hemosiderin accumulation; rheumatoid arthritis can be differentiated from LA by the intermediate signal on T1WI and the decreased signal on T2WI. Synovial chondromatosis and hemangiomas show low-to-intermediate signal intensities on T1WI and T2WI. The treatment for LA is open or arthroscopic arthrotomy and synovectomy.
Shin splints (medial tibial stress syndrome)
Medial tibial stress syndrome, also known as shin splints, describes a spectrum of stress injury that occurs at the medial tibia. This pain is usually at the front outside part of the lower leg but can also occur in the foot and ankle (anterior shin splints) or where the bone meets the calf muscles at the inner edge of the bone (medial shin splints). Shin splints are common with runners and even more so when the runner runs on hard surfaces. Failing to warm up or stretch, improper running techniques, running in shoes that lack proper support, or having “flat feet,” all can contribute to shin splints. Athletes with shin splints complain of pain in the lower leg bone or the tibia. Shin splints are most often found in athletes who are runners or participate in activities with a great deal of running, such as soccer. Athletes typically get shin splints diagnosed early in their season as they increase activities or mileage too quickly. MRI is the most sensitive radiological examination (~88%). It may demonstrate a spectrum of findings ranging from normal to periosteal fluid to marrow edema to actual stress fracture. The anterior cortex (± posterior cortex) is most commonly affected. Shin splints are best prevented and/or treated with rest, icing, and gradually increasing running activities. Purchasing shoes with good arch support can also reduce pain in the shins and help with recovery.
Bursae are small, jelly-like sacs that are located throughout the body, including around the shoulder, elbow, hip, knee, and heel. They contain a small amount of fluid and are positioned between bones and soft tissues, acting as cushions to help reduce friction. Bursitis is inflammation of a bursa. Repeated small stresses and overuse can cause the bursa in the shoulder, elbow, hip, knee, or ankle to swell. Many people experience bursitis in association with tendinitis. Bursitis can usually be relieved by changes in activity and possibly with anti-inflammatory medications. Although surgery is rarely necessary for bursitis, if the bursa becomes infected, an operation to drain the fluid from the bursa may be necessary.
A sprain is a stretch and/or tear of a ligament, a strong band of connective tissue that connects the end of one bone with another. Ligaments stabilize and support the body's joints. The areas of the body that are most vulnerable to sprains are ankles, knees, and wrists. A sprained ankle can occur when your foot turns inward, placing extreme tension on the ligaments of your outer ankle. A sprained knee can be the result of a sudden twist, and a wrist sprain can occur when falling on an outstretched hand. Sprains are classified by severity: Grade 1 sprain (mild): Slight stretching and some damage to the fibers (fibrils) of the ligament; Grade 2 sprain (moderate): Partial tearing of the ligament. There is abnormal looseness (laxity) in the joint when it is moved in certain ways; Grade 3 sprain (severe): Complete tear of the ligament. This causes significant instability and makes the joint nonfunctional. Treatment for mild sprains includes RICE and sometimes physical therapy exercises. Moderate sprains often require a period of bracing. The most severe sprains may require surgery to repair torn ligaments.
A strain is an injury to a muscle and/or tendons. Strains often occur in your foot, leg (typically the hamstring), or back. Similar to sprains, a strain may be a simple stretch in your muscle or tendon, or it may be a partial or complete tear in the muscle-and-tendon combination. Typical symptoms of a strain include pain, muscle spasm, muscle weakness, swelling, inflammation, and cramping. Soccer, football, hockey, boxing, wrestling, and other contact sports put athletes at risk for strains, as do sports that feature quick starts, such as hurdling, long jump, and running races. Gymnastics, tennis, rowing, golf, and other sports that require extensive gripping have a high incidence of hand sprains. Elbow strains frequently occur in racquet, throwing, and contact sports. The recommended treatment for a strain is the same as for a sprain: rest, ice, compression, and elevation. This should be followed by simple exercises to relieve pain and restore mobility. Surgery may be required for a more serious tear.
A contusion is a bruise caused by a direct blow or repeated blows, crushing underlying muscle fibers and connective tissue without breaking the skin. A contusion can result from falling or jamming the body against a hard surface. The discoloration of the skin is caused by blood pooling around the injury. Most contusions are mild and respond well with the RICE protocol. If symptoms persist, medical care should be sought to prevent permanent damage to the soft tissues.
Lateral ankle sprain
Lateral ankle sprains most commonly occur due to excessive supination of the rear foot about an externally rotated lower leg soon after initial contact of the rear foot during gait or landing from a jump. The anterior talofibular ligament (ATFL) is the first to rupture with such forced inversion of the ankle. Rupture of the ATFL is always associated with rupture of the joint capsule because the ligament is incorporated into capsule. Rupture of ATFL because of forced inversion allows the anterior subluxation of the talus out of the ankle mortise. Forced plantar flexion in combination with adduction causes rupture of the ATFL, followed by partial rupture of calcaneofibular ligament (CFL). If the continued force is applied, then CFL ruptures completely followed by the rupture of posterior talofibular ligament (PTFL). The PTFL is rarely injured during inversion ankle sprains. Plain films of the ankle are the first line for imaging studies. Weight-bearing radiographs are imperative to assess the overall alignment of the ankle and foot. Stress radiographs comparing the affected side to the unaffected sign are the gold standard in diagnosis mechanical stability. A difference of >3 mm in anterior drawer and >3° on talar tilt is significant for instability. While plain films are limited in assessing the soft tissue, osseous pathology including fractures and arthritis can be seen. MRI is a useful adjunct in assessing the soft-tissue structures as well as chondral injury. Without dynamic imaging studies, MRI is limited in making a diagnosis of instability, but changes in ligamentous morphology can be appreciated. There is utility for MRI in preoperative planning for patients who fail conservative management.
Achilles tendinitis is tendinitis of the Achilles tendon, generally caused by overuse of the affected limb, and is more common among athletes training under less than ideal conditions. Achilles tendinitis is a common injury, particularly in sports that involve lunging and jumping. During the loading phase of the running and walking cycle, the ankle and foot naturally pronate and supinate by approximately 5°. Excessive pronation of the foot (over 5°) in the subtalar joint is a type of mechanical mechanism that can lead to tendinitis.
Tendinitis is an inflammation or irritation of a tendon or the covering of a tendon. It is caused by a series of small stresses that repeatedly aggravate the tendon. Symptoms typically include swelling and pain that worsens with activity. Professional baseball players, swimmers, tennis players, and golfers are susceptible to tendinitis in their shoulder and arms. Soccer and basketball players, runners, and aerobic dancers are prone to tendon inflammation in their legs and feet. Tendinitis may be treated by rest to eliminate stress, anti-inflammatory medication, steroid injections, splinting, and exercises to correct muscle imbalance and improve flexibility. Persistent inflammation may cause significant damage to the tendon, which may require surgery.
As more and more people recognize the health benefits of exercise and become active, it is important to understand how to participate in sports activities safely. Collision or contact sports have higher injury rates – football, basketball, baseball, and soccer account for about 80% of all sports-related emergency room visits for children between 5 and 14 years of age. While teens and adolescents experience injuries related to the force they can generate and the intensity of play, children in this age group are less proficient at assessing risks and have less coordination, slower reaction times, and less accuracy than adults. While sports-related injuries are not entirely preventable, taking necessary precautions can help to decrease them significantly. This review article is an attempt to brief the readers about the head to toe spectrum of sports-related injuries.
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|1||Arnold A, Thigpen CA, Beattie PF, Kissenberth MJ, Shanley E. Overuse physeal injuries in youth athletes. Sports Health 2017;9:139-47.|
|2||Lovell MR, Collins MW. Neuropsychological assessment of the college football player. J Head Trauma Rehabil 1998;13:9-26.|
|3||Macciocchi SN, Barth JT, Alves W, Rimel RW, Jane JA. Neuropsychological functioning and recovery after mild head injury in collegiate athletes. Neurosurgery 1996;39:510-4.|
|4||Kumamoto DP, Maeda Y. A literature review of sports-related orofacial trauma. Gen Dent 2004;52:270-80.|
|5||Borum MK, Andreasen JO. Therapeutic and economic implications of traumatic dental injuries in Denmark: An estimate based on 7549 patients treated at a major trauma centre. Int J Paediatr Dent 2001;11:249-58.|
|6||Padilla R, Balikov S. Sports dentistry: Coming of age in the '90s. J Calif Dent Assoc 1993;21:27-34, 36-7.|
|7||Meyer RA. Clicking sounds owing to temporomandibular joint injury. JAMA 1982;248:30.|
|8||Torg JS, Vegso JJ, O'Neill MJ, Sennett B. The epidemiologic, pathologic, biomechanical, and cinematographic analysis of football-induced cervical spine trauma. Am J Sports Med 1990;18:50-7.|
|9||Itoi E, Minagawa H, Yamamoto N, Seki N, Abe H. Are pain location and physical examinations useful in locating a tear site of the rotator cuff? Am J Sports Med 2006;34:256-64.|
|10||D'Alessandro DF, Bradley JP, Fleischli JE, Connor PM. Prospective evaluation of thermal capsulorrhaphy for shoulder instability: Indications and results, two- to five-year follow-up. Am J Sports Med 2004;32:21-33.|
|11||Clement ND, Nie YX, McBirnie JM. Management of degenerative rotator cuff tears: A review and treatment strategy. Sports Med Arthrosc Rehabil Ther Technol 2012;4:48.|
|12||Reinold MM, Wilk KE, Reed J, Crenshaw K, Andrews JR. Interval sport programs: Guidelines for baseball, tennis, and golf. J Orthop Sports Phys Ther 2002;32:293-8.|
|13||Shiri R, Viikari-Juntura E. Lateral and medial epicondylitis: Role of occupational factors. Best Pract Res Clin Rheumatol 2011;25:43-57.|
|14||Kaplan LD, Flanigan DC, Norwig J, Jost P, Bradley J. Prevalence and variance of shoulder injuries in elite collegiate football players. Am J Sports Med 2005;33:1142-6.|
|15||Dingemanse R, Randsdorp M, Koes BW, Huisstede BM. Evidence for the effectiveness of electrophysical modalities for treatment of medial and lateral epicondylitis: A systematic review. Br J Sports Med 2014;48:957-65.|
|16||Dey R, Green AD. The danger in a handshake – an unusual case of ulnar collateral ligament rupture. Injury 2003;34:535-6.|
|17||Benzon HT, Katz JA, Benzon HA, Iqbal MS. Piriformis syndrome: Anatomic considerations, a new injection technique, and a review of the literature. Anesthesiology 2003;98:1442-8.|
|18||Schilders E, Dimitrakopoulou A, Cooke M, Bismil Q, Cooke C. Effectiveness of a selective partial adductor release for chronic adductor-related groin pain in professional athletes. Am J Sports Med 2013;41:603-7.|
|19||Ekberg O, Sjöberg S, Westlin N. Sports-related groin pain: Evaluation with MR imaging. Eur Radiol 1996;6:52-5.|
|20||Siegel AJ, Hennekens CH, Solomon HS, Van Boeckel B. Exercise-related hematuria. Findings in a group of marathon runners. JAMA 1979;241:391-2.|
|21||Irving RA, Noakes TD, Irving GA, Van Zyl-Smit R. The immediate and delayed effects of marathon running on renal function. J Urol 1986;136:1176-80.|
|22||Yu JS, Habib PA. Common injuries related to weightlifting: MR imaging perspective. Semin Musculoskelet Radiol 2005;9:289-301.|
|23||Alonso JM, Edouard P, Fischetto G, Adams B, Depiesse F, Mountjoy M, et al. Determination of future prevention strategies in elite track and Wfield: Analysis of Daegu 2011 IAAF Championships injuries and illnesses surveillance. Br J Sports Med 2012;46:505-14.|
|24||Teplick JG, Laffey PA, Berman A, Haskin ME. Diagnosis and evaluation of spondylolisthesis and/or spondylolysis on axial CT. AJNR Am J Neuroradiol 1986;7:479-91.|
|25||Anderson PA, McCormick PC, Angevine PD. Randomized controlled trials of the treatment of lumbar disk herniation: 1983-2007. J Am Acad Orthop Surg 2008;16:566-73.|
|26||Iguchi T, Wakami T, Kurihara A, Kasahara K, Yoshiya S, Nishida K, et al. Lumbar multilevel degenerative spondylolisthesis: Radiological evaluation and factors related to anterolisthesis and retrolisthesis. J Spinal Disord Tech 2002;15:93-9.|
|27||Pulido L, Parvizi J. Femoroacetabular impingement. Semin Musculoskelet Radiol 2007;11:66-72.|
|28||Tyler TF, Nicholas SJ, Campbell RJ, McHugh MP. The association of hip strength and flexibility with the incidence of adductor muscle strains in professional ice hockey players. Am J Sports Med 2001;29:124-8.|
|29||Weinstein JN, Lurie JD, Olson PR, Bronner KK, Fisher ES. United States' trends and regional variations in lumbar spine surgery: 1992-2003. Spine (Phila Pa 1976) 2006;31:2707-14.|
|30||Kujala UM, Orava S, Karpakka J, Leppävuori J, Mattila K. Ischial tuberosity apophysitis and avulsion among athletes. Int J Sports Med 1997;18:149-55.|
|31||Agel J, Arendt EA, Bershadsky B. Anterior cruciate ligament injury in national collegiate athletic association basketball and soccer: A 13-year review. Am J Sports Med 2005;33:524-30.|
|32||Geeslin AG, LaPrade RF. Location of bone bruises and other osseous injuries associated with acute grade III isolated and combined posterolateral knee injuries. Am J Sports Med 2010;38:2502-8.|
|33||Witvrouw E, Werner S, Mikkelsen C, Van Tiggelen D, Vanden Berghe L, Cerulli G, et al. Clinical classification of patellofemoral pain syndrome: Guidelines for non-operative treatment. Knee Surg Sports Traumatol Arthrosc 2005;13:122-30.|
|34||O'Donoghue DH. Surgical treatment of fresh injuries to the major ligaments of the knee. J Bone Joint Surg Am 1950;32 A: 721-38.|
|35||Logan M, Watts M, Owen J, Myers P. Meniscal repair in the elite athlete: Results of 45 repairs with a minimum 5-year follow-up. Am J Sports Med 2009;37:1131-4.|
|36||Lian OB, Engebretsen L, Bahr R. Prevalence of jumper's knee among elite athletes from different sports: A cross-sectional study. Am J Sports Med 2005;33:561-7.|
|37||Stanitski CL, Paletta GA Jr. Articular cartilage injury with acute patellar dislocation in adolescents. Arthroscopic and radiographic correlation. Am J Sports Med 1998;26:52-5.|
|38||Hallel T, Lew S, Bansal M. Villous lipomatous proliferation of the synovial membrane (lipoma arborescens). J Bone Joint Surg Am 1988;70:264-70.|
|39||Niemuth PE, Johnson RJ, Myers MJ, Thieman TJ. Hip muscle weakness and overuse injuries in recreational runners. Clin J Sport Med 2005;15:14-21.|
|40||Petersen W, Rembitzki IV, Koppenburg AG, Ellermann A, Liebau C, Brüggemann GP, et al. Treatment of acute ankle ligament injuries: A systematic review. Arch Orthop Trauma Surg 2013;133:1129-41.|
|41||Chen AL, Youm T, Ong BC, Rafii M, Rokito AS. Imaging of the elbow in the overhead throwing athlete. Am J Sports Med 2003;31:466-73.|
|42||Lamb SE, Marsh JL, Hutton JL, Nakash R, Cooke MW; Collaborative Ankle Support Trial (CAST Group), et al. Mechanical supports for acute, severe ankle sprain: A pragmatic, multicentre, randomised controlled trial. Lancet 2009;373:575-81.|
|43||Alfredson H, Lorentzon R. Chronic Achilles tendinosis: Recommendations for treatment and prevention. Sports Med 2000;29:135-46.|