Sports Injuries: Causes, Treatment, and Prevention

Many sports injuries can occur while a sportsperson is muscle training or playing in general. These injuries need to be managed with utmost care so that they don't cause long-term side effects.

Most of the time, the lower limb is affected by sports injuries.

Stabilizers of Knee Joint

Anterior Cruciate Ligament Injuries 

Anatomy

• Length - 31 to 33 mm
• It is intracapsular, extra synovial.
• The key stabilizer of the knee joint. 
• It is comparatively weaker than PCL.
• The ACL comprises 90% Type I collagen and 10% Type III collagen.
• Attachments—In the Tibia, it inserts on the tibial plateau medial to the insertion of the anterior horn of the lateral meniscus. The femoral attachment is on the medial or lateral femoral condyle.
• There are two bundles of ACL.
  • Anteromedial
  • Posterolateral (Main Bulk)
• The main blood supply is from the middle Genicular artery. 
• The main nerve supply is the posterior articular nerve.
• Functions of ACL
  • It prevents posterior translation of the femur on the tibia; otherwise, anterior translation of the tibia on the femur (Menisci has a major role).
  • It has a minimal proprioceptive role.
• The quadriceps can produce an anterior translation of the tibia, which increases stress on the ACL.
• Hamstrings can negate the effect of the quadriceps. Hence, they decrease stress on the ACL.
• Intercondylar notch morphology is often blamed for the recent pathogenesis of ACL injury.
  • Female: Narrow
  • Notch stenosis: There is a higher chance of ACL injury.
• Only hamstring exercise is known as Closed-chain Physio.

Anterior Cruciate Ligament Injuries 

Anatomy

• Length - 31 to 33 mm
• It is intracapsular, extra synovial.
• The key stabilizer of the knee joint. 
• It is comparatively weaker than PCL.
• The ACL comprises 90% Type I collagen and 10% Type III collagen.
• Attachments—In the Tibia, it inserts on the tibial plateau medial to the insertion of the anterior horn of the lateral meniscus. The femoral attachment is on the medial or lateral femoral condyle.
• There are two bundles of ACL.
  • Anteromedial
  • Posterolateral (Main Bulk)

• The main blood supply is from the middle Genicular artery. 
• The main nerve supply is the posterior articular nerve.
• Functions of ACL
  • It prevents posterior translation of the femur on the tibia; otherwise, anterior translation of the tibia on the femur (Menisci has a major role).
  • It has a minimal proprioceptive role.
• The quadriceps can produce an anterior translation of the tibia, which increases stress on the ACL.
• Hamstrings can negate the effect of the quadriceps. Hence, they decrease stress on the ACL.
• Intercondylar notch morphology is often blamed for the recent pathogenesis of ACL injury.
  • Female: Narrow
  • Notch stenosis: There is a higher chance of ACL injury.
• Only hamstring exercise is known as Closed-chain Physio.

 ACL and PCL

• Crucial cross

Mechanism of Injury

• Isolated ACL tear usually results from
  • Quick deceleration.
  • Hyperextension.
  • Rotation.
  • Cutting action (changing the direction).
• When the knee joint is hit from the side, an ACL injury may be associated with a medial, meniscal, and medial collateral ligament injury—the Terrible triad or Unhappy triad of the Knee.
• Other unhappy triads
  • Shoulder
  • Elbow: Hotch kiss triad
• 'o' donoghue Unhappy Triad 

Clinic Features

• The patient usually falls to the ground and cannot get up immediately. 
• Severe swelling of the knee within a few hours – Haemarthrosis.
• Most patients have a history of giving away feelings in the knee.

Anterior Drawer test

• The patient is in the supine position.
• Knee flexed to 90°
• The examiner sits on the patient's feet.
• The thumb of both hands on tibial tuberosity.
• This test is considered positive if a 'soft end feel' exists.
• It is less accurate than the Lachman Test
• Associated medial meniscus injury.

Lachman Test

• The patient is in the supine position.
• Knee flexed to 30°
• The examiner places one hand behind the tibia, with the thumb on the tibial tuberosity, and another hand on the patient's thigh. 
• More than 2mm of anterior translation associated with a 'soft end feel' is considered positive.
• Lachman test is.
  • More reliable
  • More sensitive
  • Superior to Anterior Drawers Test
  • Less hurting to the patient.
  • No doorstep phenomenon.
  • Gold standard physical test.

Pivot Shift Test

• The Pivot Shift Test is a special test used to diagnose rotatory instability related to injury to the knee's anterior cruciate ligament (ACL).
• The patient is supine. 
• The examiner rasps and immobilizes the lateral femoral condyle with one hand and palpates the proximal tibia or fibula with the thumb. 
• On the other hand, the examiner holds the patient's lower leg in internal rotation and abduction (valgus stress).
•  From this starting position, the knee is moved from extension into flexion.
• In a torn anterior cruciate ligament, the valgus stress will cause the tibia to subluxate anteriorly while the knee is still in extension.

Investigation of Pivot Shift Test

• X-ray - It may show a tibial eminence fracture. It indicates the avulsion of the tibial attachment of the ACL.
• The SEGOND fracture is an avulsion fracture of the lateral tibial plateau, pathognomonic of an ACL tear.

MRI

• This is the investigation of choice.
• MRI knee 15° external rotation will show the entire ACL.
• Evidence of bone contusion & edema in the lateral femoral condyle near the sulcus terminalis & posterolateral aspect of the tibia is called a kissing lesion.

Treatment

• Non-Surgical Management
  • Activity modification
  • Hamstring strengthening (Closed chain physiotherapy).
• Surgical management
  • If bony avulsion is present, the avulsed fragment is fixed with sutures or a trans-osseous screw.
  • Primary repair of ACL
  • Reconstruction of ACL – This is usually the TOC. 
  • The types of grafts are.
    • Bone-Patella Tendon-Bone Graft (BTB).
    • Semitendinosus - Gracilis Muscle Graft (ST-G).

Normally, surgery is done four weeks after trauma.

Prerequisites for Reconstruction of ACL

1. The patient should have regained full ROM of the knee.
2. Good quadriceps function.
3. Normal gait.
4. There should not be any knee effusion or haemarthrosis.

Posterior Cruciate Ligament Injuries           

Anatomy

• It is twice as strong & twice as thick as the ACL.
• PCL originates from the anterolateral aspect of the medial femoral condyle & gets attached to the back of the tibial plateau.
• PCL is the primary restraint to posterior tibial translation.

Mechanism of Injury

• A direct blow to the posterior aspect of the Tibia is the MC cause.

Clinical Features

• Isolated PCL injury is often asymptomatic because instability is often subtle.
• Posterior Drawer Test Positive.
• Godfrey sign
  • This is otherwise called the Gravity Sign or Sag Sign.
  • When viewed from the side, the tibia's posterior translation is abnormal, and the contraction of the hamstrings accentuates this.

Investigations - MRI Is the IOC

Treatment

• PCL reconstruction is done through a tibial /femoral tunnel technique.
• Graft chaps include.
  • Patellar tendon-bone graft (PTB).
  • Quadriceps Tendon Bone Graft (QTB).
  • Semitendinosus/Gracilis Tendon Graft (ST-G).

Also Read: Malunion And Non Union

Meniscal Injuries       

Anatomy

• This is made up of fibrocartilaginous tissue.
• They are scent-shaped and are also known as semilunar cartilage.
• The ends are attached to the intercondylar area of the tibia. 
• The outer border is thick & convex, and the inner border is thin & concave.
• Two meniscofemoral ligaments, Humphrey & Wrisberg, are attached to the lateral meniscus. 
• They connect the posterior horn of the lateral meniscus to the medial femoral condyle (46%).
• The medial meniscus is more prone to injury because it is firmly attached to the medial collateral ligament & joint capsule.
• The blood supply is derived from meal & lateral genicular arteries.
•  Blood supply decreases with age.
• Three distinct blood supply regions
  • The outer vascular red, red zone.
  • The middle red, white zone.
  • The inner avascular white, white zone.

Functions of Menisci

• The most important function is load sharing across the knee joint.
• The menisci act as a joint filler.
• It is a joint stabilizer, especially during rotation.
• It acts as a shock absorber.
• It acts as a lubricator.
• Gives proprioception.

Meniscal Tears

• Most common in adolescents & young adults) Very rare in children.
• A meniscal tear can be.
  • Traumatic.
  • Degenerative.
• The MC site of meniscal tear is the posterior horn of the medial menisci. 
• MC type is a longitudinal tear.
• Discoid meniscus is more common in lateral menisci.

O’Connor Classification

Clinical Features

• Patients complain of pain in the joint line, more commonly at the posteromedial part of the knee.
• Mechanical symptoms include (Pain is the most common symptom).
  • Painful clicking
  • Popping
  • Locking - More common with bucket handles.
  • Catching
  • Giving 

D/D for True Locking

• Locking has 2 types.
• True locking
• Pseudo locking
  • Meniscal tear
  • Loose bodies
  • Intra Articular tumor
• False locking occurs in Hamstring spasms.
•  True locking from false locking can be differentiated when rest is given for 24 hours, and the locking disappears. It is pseudo-locking.

Clinical Test 

McMurray Test

• Step-I: Patient is in the supine position. 
• The examiner holds the knee & palpates the joint line. The other hand holds the sole.
• Step II: He is kept in full flexion.
• Step III: The examiner applies valgus stress to the knee. On the other hand, the foot and leg are externally rotated.
• Step IV: The knee is gradually extended.
• Step-V: Audible click & pain denotes medial meniscal tear.

Apley's Grinding Test

• Step I - Patient prone position with knee flexed to 90°
• Step II - The patient's thigh is fixed to the examination table with the examiner's knee.
• Step III- The examiner medially & laterally rotates the tibia combined with distraction. If there is pain associated with excessive rotations, it is a ligamentous injury. 
• Step IV - The examiner medially & laterally rotates the tibia combined with compression. 

If there is pain associated with the restriction of rotations, it is a meniscal injury.

•  Apley's Grinding Test has 87% specificity & 97% sensitivity. 

Investigations

• X-Ray - AP lateral view is done in a standing position.
• MRI - is the IOC. MRI has 98% accuracy for MM tear & 90% accuracy.
• Diagnostic Arthroscopy.

Treatment

Non-Surgical Treatment- Indications

• Incomplete Meniscal tear.
• A small stable tear without ACL injury.
• A stable vertical tear in Red- Red Zone.
• Contraindication: Acute meniscal injury with mechanical symptoms

Methods

• Groin to ankle cylinder cast or Knee immobilizer for 6 weeks. 
• Crutch walking with touch-down weight bearing.
• Progressive isometric exercise for Quadriceps, Hamstring & knee joints.

Surgical Treatment

• Arthroscopic meniscal Repair - This is indicated only in a vertical longitudinal in the Red Redo zone. 
• Arthroscopic partial Meniscectomy - Is indicated for radial, oblique, flat horizontal tears & any tear in the White zone.

Also Read: Rib Fracture: Causes, Symptoms, Risk Factors, Diagnosis, Treatment, Prevention and Complications

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