SPORTS MEDICINE PM&R

Sports Medicine Sports Medicine

Greater than 10 million sports injuries occur
each year

With increase in activity there has been a steady

Department of Physical Medicine and Rehabilitation increase in injuries over the last several decades
UMDNJ-
UMDNJ-NJ Medical School
Newark, NJ

Weekend warrior, Fitness boom
Credits to:
Scott Nadler, D.O.
Peter Yonclas, M.D.
Jonas Sokolof,
Sokolof, D.O.

Sports Injuries Sports Medicine

Soft Tissue Injuries

Most are overuse or repetitive injuries
Sprain
from micro-
micro-trauma
Strain

Contusion

Most are soft tissue injuries

Overload and overuse-
overuse-
tendons, ligaments,

Most treated non-
non-surgically muscle (weakest link)

Physiology - Tendon Physiology-

Physiology-Tendon

Aid in transmitting
Variable blood supply
muscle force to bone
Compromised in areas
of friction, torsion and

Composed of collagen compression
fibers meshed with
supraspinatus, achilles,
achilles,
elastin and proteoglycan posterior tibilais
ground substance
Increasing collagen
cross-
cross-linking causes loss
of distensibility as we age

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Physiology - Ligaments Physiology - Cartilage

Help stabilize joints
Shock absorber

Enhance Joint
Rarely has blood supply
Proproprioception
Requires mechanical

Minimal blood supply loading and unloading

Poor healing for nutrition

Acute or degenerative
tears

Physiology - Bone Sprain

Dynamic tissue
Injury to a ligament

Remodels in response to
external stress
Microscopic tear in the

Subject to repetitive fiber of the ligament
overload-
overload-i.e.
i.e. stress
fracture

Sprain Strain

Three grades
Damage to the muscle

Grade I-
I-Slight tear in the unit (muscle, tendon, or
fiber attachment)

Pain

No Laxity

Grade II-
II-Partial tear
Due to overuse or

Pain overload

LAXITY with firm end
point

Grade III-
III-Complete tear
Can also be divided into

NO ENDPOINT-
ENDPOINT- 3 degrees
complete disruption

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Principles of Sports Rehabilitation Principles of Sports Rehabilitation

Pain relief/protection
PRICE

Range of Motion
Protection-
rotection-cane, crutches, cast, brace

Strengthening
Relative Rest-
Rest-continue with some conditioning

Proprioception
Ice-
ce-pain relief, limits edema, inflammation

Functional Rehabilitation
Compression-
ompression-ace wrap, tubigrip

Elevation-
levation-reduce inflammation

Range of Motion Strengthening

Prevent contracture Terminology

Promotes collagen
Isotonic - constant resistance
healing in a linear fashion
Isometric - no shortening or lengthening of muscle

Neuromuscular
Contraindicated in tendinopathies (impaired blood
engram/movement
engram/movement flow)
pattern

Isokinetic - constant rate or velocity

Stretching

Concentric - shortening contraction

Eccentric - lengthening contraction

Proprioception/Agility Functional Rehabilitation

“Re-
Re-Tuning”
Tuning” muscle
Sport/occupation
feed back system specific
(mechanoreceptors)
Simulate sports activity

Joint specific (Wobble
Emphasize proper
board/Swiss ball) technique/posture

Provides stability by
coordinated contraction
of muscles about a joint

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Achilles Tendonitis

Begins with peritendon inflammation
Common Injuries in
Micro-
Micro-tears, fissuring and scarring
the Athlete
Most commonly seen in runners

increased mileage

interval training

downhill running

Achilles Tendonitis
Achilles Tendinitis
Treatment

Tender along achilles
Decrease inflammation

tendon
Stretching

Thickening of tendon
Strengthening (eccentric?)

Achilles Tendon Rupture

Achilles Tendon Rupture
H&P

Sudden “kick”
kick” in achilles

30 - 40 years of age

Weak plantar flexion

More common in
professionals or white
Exam
collar jobs
Feel for tendon defect

Thompson Test

Weakness

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Achilles Tendon Rupture

Treatment Patellofemoral Pain Syndrome

Controversial
“Runner’
Runner’s knee”
knee” or

Surgical
Chondromalacia
patella

Conservative (non-
(non-surgical)

Most common

May depend on activity problem in runners
level
Lateral tracking of
patella

Patellofemoral Pain Syndrome Patellofemoral Pain Syndrome

Lateral tracking History

VMO insufficiency
Anterior knee pain

ITB tightness
Worse with sitting-
sitting-steps (movie theater

Hyper-
Hyper-pronation sign), climbing

Hip abductor weakness
Improves while exercising

Patella positioning/tracking
Worsens after exercising

Patellofemoral Pain Syndrome Patellofemoral Pain Syndrome

Physical Exam Treatment

Tenderness along patellar
Reduce inflammation, control pain
articulating facets
Ice, Ice, Ice

Medial > Lateral

NSAID’
NSAID’s

ITB tightness

Avoid excessive patellar pressure

Check alignment and
biomechanics
kneeling, hyperflexion,
hyperflexion, deep squats

Stretch ITB, rectus femoris, Hamstrings and
gastrocnemius

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Patellofemoral Pain Syndrome Lateral Epicondylitis

Treatment “Tennis Elbow”
Elbow”

Strengthen Quads (VMO), hip abductors
30 - 50 years of age

Restore biomechanics
Pain radiating from lateral
epicondyle

orthotics

knee sleeve with lateral buttress

Involves extensor mechanism
of the wrist

taping

Microtears,
Microtears, fibrosis,
granulation tissue

Incomplete inflammatory
reaction?

Lateral Epicondylitis
Lateral Epicondylitis
Treatment

Pain in lateral elbow

Reduce inflammation if acute

Weak grip

Tender distal to lateral
Reduce Pain
epicondyle
Stretch

Pain with passive
Strengthen (eccentric?)
stretching and resisted
activation of wrist/finger

Local injection-
injection-Corticosteroid
extensors

Impingement/Rotator Cuff Tears Impingement/Rotator Cuff Tears

Biomechanics Biomechanics

4 joints
Dynamic stabilizers

Sternoclavicular
Rotator cuff muscles

AC (Supraspinatus,

glenohumeral infraspinatus, teres minor

scapulothoracic and subscapularis)

Static stabilizers
Scapular stabilizers (traps,

glenoid labrum rhomboids, serratus

glenohumeral ligaments anterior, levator scapula)

coracohumeral ligaments
long head of biceps

Major movers

Deltoid, Pectoralis,
latissimus dorsi

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Shoulder Impingement Shoulder Impingement

Lack of balanced firing of
Pain in anterior shoulder
scapular stabilizers, rotator
cuff and deltoid
Radiates to lateral arm

Muscle imbalance (back and
Tenderness in subacromial space
chest)

Elevation of humeral head
Neer’
Neer’s test - abduct internally rotated arm

Pinching between acromion eliciting pain
and humeral head Hawkin’

Hawkin’s, Empty can test

Supraspinatus is most
commonly compressed

Rotator Cuff Tears Rotator Cuff Tears

95% initiated by
impingement
Similar in presentation to impingement

Secondary to repetitive
Weakness of external rotation, weakness on
microtrauma and empty can test
occasionally single
Superior subluxation of humeral head on X-
X-rays
trauma

Hypovascular zone of
supraspinatus is the most
common

Impingement/Rotator Cuff Tears Impingement/Rotator Cuff Tears

Rehabilitation Rehabilitation

Control Pain
Strengthen Rotator cuff
muscles

Stretch Pectoralis muscles and Posterior capsule

To strengthen

Strengthen Scapular stabilizers supraspinatus avoid

Restore balance between glenohumeral and impingement by turning
scapular muscle groups thumb upwards (full can)

Incorporate dynamic
stability

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Low Back Pain Low Back Pain

60 - 90% of people
experience back pain in their
lifetimes.

There are many pain
generators in the back.

The differential diagnosis is
extensive

Low Back Pain Low Back Pain

Simple Differential Treatment

Pain Control

Neurologic (ie
(ie radicular)
Flexibility (quadriceps, illiopsoas,
illiopsoas, hamstrings)

Mechanical
Strengthening (abdominal muscles, quads,

Anterior elements (ie(ie disk) gluteus, lats and spine extensors)

Posterior elements (ie(ie facets,
Stabilization (Neuromuscular and balance
pars interarticularis) training)

Muscle strain

Diagnosis?

Spondylolysis

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Spondylolysis Spondylolysis

Symptomatic in athletes
Fracture (stress or true)
who load posterior of pars interarticularis
elements-
elements-gymnastics,
Obtain oblique x-x-rays, if
football, tennis, weight negative CT or MRI with
lifting SPECT

PE: Low back pain,
Often do well with
worse with extension and conservative treatment
oblique extension, tight
NSAIDs, rest, physical
hamstrings therapy

Spondylolysis

Thank You !

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