FOP Injuries in Different Sports

And their Prevention

Dr Sachin Khullar
MBBS MS ortho DNB ortho Dip Sports med FACSEP
Australasian College of Sports and Exercise Medicine
GAMES EXPERIENCE
 DISCLAIMER

I currently work as a Sports and Exercise medicine Specialist In Australia

No funding has ben received for this presentation

Acknowledgement
Would like to acknowledge SAI and NIS for the opportunity to share
my thoughts on this topic

ACSEP
 WHY SHOULD I LEARN ABOUT FOP INJURY
AND PREVENTION. Why do we have the medical
COACH team then……

DOCTOR
& medical team
Mechelen et al
Establish the
extent of the
problem

Assesseign
the
effectiveness
Injury Establish
etiology and
of the
measure Prevention mechanism

Introduce
preventive
measure
 Athlete injury

2 Basic questions ( generally)

Prevention (TEA)to:
Change the Questions

What do1.you
Training do:big Is the injury? (And not what is the injury)
level
How
ISL
Equipment
Immediately level
Athlete level or medical room ( Short term)
On the side-line
2. When
In the coming can
days the Athlete
( Long term) return to sport ?
PREVIEW
Collapsed Athlete
Runner with Midfoot pain
Apophyseal Injuries
Rower with Chest pain
Wrestler with Skin rash
Parathlete with HTN
 CASE 1

22 year old footballer has a head collision with an Opponent

Goes to the ground
Clenches his head

What do you do ?:

Immediately
Short term
Long term
 Immediate action

• RUN TO THE FIELD ( depending on rules)

• AVPU ( Alert, responding to Vocal commands,
Responding to Pain, Unresponsive
• For P, U Initiate DRABC- Cervical spine
• For A, V: Cervical spine and then Assess for
Concussion and neurology
Concussion- what it means
• Trauma to head: more than this

üHead hits the ground

üArm hits the head
üHead clash
üBall hitting the head

üNo head contact- rapid head motion

Game day…….

d ay
sa me
o n the
to p lay
et ur n
No r
 Send to hospital immediately if:

a) Prolonged LOC or deterioration of consciousness

b) Seizures

c) Neurological signs or Spinal cord signs

d) Persistent vomiting or increasing headache post-injury

e) Skull Fracture

f) Risk that assessment can’t be done later on

OR

If you have any doubt….

 SHORT TERM and LONG-TERM ACTION
……….Return to play

• Recovery from all symptoms

• Graded rehabilitation—increasing severity of training
• Keep contact training at the last
• No recurrence of symptoms
• Return to Play

COGSPORTS
Early Neuro-vestibular rehab
CONCUSSION RECOGNITION TOOL 5 ©
To help identify concussion in children, adolescents and adults Role of helmets & mouthguards
RECOGNISE & REMOVE in Australian Football
Head impacts can be associated with serious and
potentially fatal brain injuries. The Concussion
Recognition Tool 5 (CRT5) is to be used for the
STEP 3: SYMPTOMS Helmets Mouthguards
designed to diagnose concussion.
• Headache • “Don’t feel right” There is no definitive scientific Mouthguards have a definite role in
• “Pressure in head” • More emotional
evidence that helmets prevent preventing injuries to the teeth and face
STEP 1: RED FLAGS — CALL AN AMBULANCE • Balance problems • More irritable
concussion or other brain injuries and for this reason they are strongly
• Nausea or vomiting • Sadness
If there is concern after an injury, including
• Drowsiness • Nervous or anxious
in Australian Football. recommended at all levels of football.
whether ANY of the following signs are observed Mouthguards should be worn for all
or complaints are reported, then the player • Dizziness • Neck pain Helmets may have a role in the
• Blurred vision • games and training sessions.
should be safely and immediately removed from protection of players on return to play
play/game/activity. If no licensed healthcare • Sensitivity to light •
following specific injuries (e.g. face or Dentally-fitted laminated mouthguards
professional is available, call an ambulance for • Sensitivity to noise • Feeling slowed down
urgent medical assessment: skull fractures). offer the best protection. ‘Boil and
• Fatigue or low energy • Feeling like “in a fog“
bite’ type mouthguards are not
• Neck pain or • Loss of Overall, however there is insufficient
STEP 4: MEMORY ASSESSMENT recommended for any level of play as
http://www.sportsconcussion.co.za/Concussion/CogSportFlyer.pdf
tenderness consciousness
(IN ATHLETES OLDER THAN 12 YEARS)
scientific evidence to make a
• Double vision • Deteriorating they can dislodge during play and block
• Weakness or conscious state recommendation for the use of helmets
the airway.
tingling/burning in • Vomiting for the prevention of concussion in
arms or legs • Increasingly appropriately for each sport) correctly may suggest
a concussion: Australian Football. There is some preliminary scientific
• Severe or increasing restless, agitated
headache or combative • “What venue are we “What team did
evidence that mouthguards may
• Seizure or convulsion at today?” you play last prevent concussion or other brain
• “Which half is it now?” week/game?” injuries in Australian Football.(3)
• “Who scored last in • “Did your team win
: this game?” the last game?”
• In all cases, the basic • Do not attempt to
move the player (other Athletes with suspected concussion should: References
(danger, response, than required for
airway, breathing, airway support) unless • Not be left alone • Not be sent home
circulation) should trained to so do. initially (at least by themselves. They 1. McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion
be followed. • Do not remove a
need to be with a in sport-the 5th international conference on concussion in sport held in Berlin,
• Not drink alcohol. responsible adult.
• Assessment for a helmet or any other October 2016. Br J Sports Med 2017 doi: 10.1136/bjsports-2017-097699
spinal cord injury equipment unless • Not use recreational/ • Not drive a motor
is critical. trained to do so safely. prescription drugs. vehicle until cleared to 2. Echemendia RJ, Meeuwisse W, McCrory P, et al. The Concussion Recognition Tool
do so by a healthcare
5th Edition (CRT5). Br J Sports Med 2017 doi: 10.1136/bjsports-2017-097508
professional.

STEP 2: OBSERVABLE SIGNS

Visual clues that suggest possible concussion include:
• Lying motionless on the • Blank or vacant look
playing surface • Balance, gait
The CRT5 may be freely copied in its current form
for distribution to individuals, teams, groups and
organisations. Any revision and any reproduction in
https://www.cdc.gov/headsup/youthsports/training/index.html
3. Emery CA, Black AM, Kolstad A, et al. What strategies can be used to
effectively reduce the risk of concussion in sport? Br J Sports Med 2017
doi:10.1136/ bjsports-2016-097452.
a digital form requires approval by the Concussion
in Sport Group. It should not be altered in any way,
rebranded or sold for commercial gain.

HEADS UP to Youth Sports: Coaches

• Slow to get up after a ANY ATHLETE WITH A SUSPECTED
direct or indirect hit to incoordination, CONCUSSION SHOULD BE IMMEDIATELY
the head stumbling, slow REMOVED FROM PRACTICE OR PLAY
• Disorientation or laboured movements AND SHOULD NOT RETURN TO ACTIVITY
confusion, or inability • Facial injury after UNTIL ASSESSED MEDICALLY, EVEN IF THE
to respond appropriately head trauma SYMPTOMS RESOLVE
to questions
14 B. FOLLOW-UP MANAGEMENT © Concussion in Sport Group 2017
THE MANAGEMENT OF CONCUSSION IN AUSTRALIAN FOOTBALL 15
 PREVENTION STRATEGIES
• TRAINING
EQUIPMENT LEVEL:LEVEL
HELMETS?, MOUTH GUARDS?

ATHLETE LEVEL safe rules : RUGBY, TACKLING, CONTACT CARE, HEADING

- Enforce
OF SOCCER BALLS
-Education
- Training surfaces
-Concussion Action plan: Remove from play, No return to play on the same day…IF
IN DOUBT…SIT THEM OUT
- Encourage sportsmanship, rewards and Punishments
-Neck muscle strength, Balance and proprioception, Landing techniques, avoid
impacts- Concussion Reporting ( concussion reporting Doctor)
 SUMMARY
Condition Immediate action Short term Action Long term Action

Athlete with Concussion ABC, Stop participation SCAT-5 Neurological Prevent Post Concussion
Cervical spine assessment Symptomatic recovery Syndrome
Assess if hospital transfer is Cogsport, ImPACT Neuropsychological testing
required Neurovestibular rehab
 CASE 2

22 yr old runner reports midfoot pain

Ongoing from few days
Progressively worsening

What do you do ?:

Immediately
Short term
Long term
 EVALUATION
• Where exactly is the pain

• Special characteristics associated

with running, rest and night sleep

• Previous hx

• Medical hx, red flags

• Diet
RULE OUT NAVICULAR STRESS FRACTURE
• Training

• Footwear

• Surface
Important sign: “ N- Spot” tenderness
Mechanism of Injury
Staging of stress Fracture
 Treatment

CAUTION
NON-OPERATIVE Operative
• Screw across #. Percutaneous or
open and bone graft.
PLEASE DON’T TAKE THIS
• IMMOBILISE
• Complete # two cortices (Saxena
INJURY LIGHTLY
• Graduate RTP
III) probably
• ADL, water running/swimming à
jogging à running
• NON UNION
àsprint/takeoff/cutting
• High level athletes
CAN BE predisposing
• Correct CAREERfactors
ENDING
• FAILED CONSERVATIVE RX
INJURY
• Maybe quicker RTP?
 Prevention Strategies
TRAINING LEVEL ATHLETE LEVEL
Training error – repetitive high level or rapid
increase training load Decreased ankle DF
• Esp. jumping, push-off, sprinting, cutting
Stiff subtalar joint
Short 1st MT plus long 2nd MT

EQUIPMENT LEVEL ( Morton foot)

• SHOES Forefoot Varus

• SURFACE Variable reports regarding foot
posture
Kinetic chain Deficits
 SUMMARY
Condition Immediate action
Athletes with Concussion ABC, Stop participation
Cervical spine assessment
Assess if hospital transfer is
required
Runner with Midfoot pain Assessment to rule out
Navicular stress fracture
N-Spot
Stop running
Short term Action
SCAT-5 Neurological
Symptomatic recovery
Neurovestibular rehab
Staging of the stress fracture
Non-operative Rx
Operative Rx
Long term Action
Prevent Post Concussion
Syndrome
Neuropsychological testing
Rehab and Return to play
Address risk factors
Case 3

12 yr Adolescent with Heel pain

Comes with running
Now pain even on walking and rest
Immediate Action

Where is the pain

Relation of pain to activity
Rest or night pain
Recent training: volume, intensity, recovery
Training surface
Footwear
Red flags: weight loss, night pain, loss of
appetite, unusual fatigue
Differential diagnosis
Causes

Local causes Calcaneal Apophysitis, Achilles tendinopathy, Ankle sprain, planter

Local causes fascitis, tarsal Coalition, Bursitis, TP apophysitis

Referred causeRA, JRA, ref from spine

Referred/systemic
causes

Red flags
Red flags Infection, osteomyelitis, Bony tumour
Features to suggest Calcaneal Apophysitis- Sever’s disease
• Posterior inferior heel pain

• Almost no pain when waking up

Sports Involved:
• Activity related increase in pain and stiffness– may
limp Running and Impact-ballistic
• Tenderness at the insertion of the Achilles tendon

• Limited ankle dorsiflexion

• Hard surfaces and poor-quality or worn-out athletic

shoes
Short term action Long term action

• “POLICE” Biomechanical correction

• Rest from aggravating activities Adjust training loads

• Anti-inflammatory medication
• Heel lift Footwear and taping
• Ice
Patient and parent education
• Local ointments
- Growth spurts
• Padded heel counter
• Supportive shoes Reassurance

Imaging if any doubt

Growth centers
 SUMMARY
Condition Immediate action
Athletes with Concussion ABC, Stop participation
Cervical spine assessment
Assess if hospital transfer is
required
Runner with Midfoot pain Assessment to rule out
Navicular stress fracture
N-Spot
Stop running
Adolescent with heel pain Assessment
POLICE
Short term Action
SCAT-5 Neurological
Symptomatic recovery
Neurovestibular rehab
Staging of the stress fracture
Non-operative Rx
Operative Rx
Intial treatment
Activity modification
Long term Action
Prevent Post Concussion
Syndrome
Neuropsychological testing
Rehab and Return to play
Address risk factors
Biomechanical correction
Training loads
Education
CASE 4
Rower with Chest pain
Rower with chest pain

• 23 yr
• Participating in camp
• High volume (200 km / 3 days)
• High intensity
• Rough water
Immediate Action

• No history of chest wall pain or

stress fracture

• Developed right chest pain during

row

• Stopped immediately

• Gentle row back to shed

Assessment

• Night pain
• Pain with ADLs
• Pain with deep
inspiration
• Cough
• Sit up
• Push up
• Thoracic spring
Courtesy D Huges AIS
INVESTIGATION

RIB STRESS FRACTURE

INVESTIGATION--- CT SCAN
 RISK FACTORS

• Intrinsic risks • Extrinsic risks

- Low BMI -Training volume and

- RED- S intensity
-Environmental
- Biomechanics
-Equipment: Oar
- Thoracic mobility
type, shaft length,
- Kinetic Chain boat size, experience
- Medical causes of crew
BIOMECHANICS
 Prevention Strategies
TRAINING LEVEL

• Training loads- volume and Intensity sweeps or scull

• Technique: Drive phase (catch, mid rive, finish) and recovery phase ( feathering)
• Environmental
• Land based training

EQUIPMENT LEVEL
• Weight and Size of Equipment

ATHLETE LEVEL

• Biomechanical issues
• Kinetic chain
• Warm-up and land-based training (Ergometers)
Key messages

• Significant lost time among elite rowers

• Stop immediately if Rower develop chest wall pain
• Pain poorly localised
• Early diagnosis does not necessarily save the athlete from
cortical fracture
• Bone scan is more sensitive than the USS
 SUMMARY
Condition Immediate action
Athlete with Concussion ABC, Stop participation
Cervical spine assessment
Assess if hospital transfer is
required
Runner with Midfoot pain Assessment to rule out
Navicular stress fracture
N-Spot
Stop running
Adolescent with heel pain Assessment
POLICE
Rower with Chest pain Stop activity
Initial assessment
Bone scan/CT
Staging of the stress #
Short term Action
SCAT-5 Neurological
Symptomatic recovery
Neurovestibular rehab
Staging of the stress fracture
Non-operative Rx
Operative Rx
Intial treatment
Activity modification
Healing of the fracture
Long term Action
Prevent Post Concussion
Syndrome
Neuropsychological testing
Rehab and Return to play
Address risk factors
Biomechanical correction
Training loads
Education
Correct biomechanics
 Case 5
Wrestler with
Skin rash

Primary Herpes
Gladiatorum
Herpes
(1991) Gladiatorum-
Prevalence in wrestlers:
Presentation
2.6-29% High School Herpes Gladiato
7.6-12.8% Collegiate
20-40% Division I
Location
Presentation
73% on Head and Face
42% on Extremities Location
Herpes Gladiatorum-
28% on Trunk 73% on Head and Face

contact
Presentation
Appear 3-8 days after 42% on Extremities
28% on Trunk
Primarily atLocation
locations of Appear 3-8 days after
‘Lock-up’ position
73% on Head and Face contact
42% on Extremities
Only from skin-to-skin Primarily at locations of
28% on Trunk
contact Appear 3-8 days after
‘Lock-up’ position
No association with
contact Only from skin-to-skin
mats Primarily at locations of contact
‘Lock-up’ position
Only from skin-to-skin
No association with
contact mats
No association with
mats
 HERPES GLADIATORUM

Symptoms:
Herpes Gladiatorum-Recurrent
Outbreaks
• Painful Vesicles with red base
• Malaise
• Pharyngitis
Latency
• Feverand Reactivation are the rule
Usual reoccurrences
• Lasts 10-14 days last 3-5 days
Less signs and symptoms than primary
outbreak
Brought on by stress, i.e. weight
cutting, abrading or rubbing facial skin,
sun exposure, suppressed cell-mediated
Primary HG: Note grouped vesicles on forehead and along jawline
immunity
 TREATMENT
REMOVE ATHLETE FROM PLAY
CANNOT PLAY TILL ALL VESCICLE GET DRY and no
NEW VESCICLES in 48 HRS
CANNOT COVER THE RASH AND PLAY
CAN SPREAD TO OTHER ATHLETES
ANTI VIRAL DRUGS
CONSIDER TREATING OTHER TEAM MEMBERS
EQUIPMENT AND PERSONAL HYGIENE
PREVENTION
Personal Hygiene
Equipment Hygiene
Avoid overtraining and Fatigue
General conditioning
Consider treatment for the whole team
MYTHS
Not Sexually Transmitted
It can occurs even if you wash the mat
Its different from Herpes- cold sore
Its different from other skin infections which are
more common in athletes
 SUMMARY
Condition Immediate action Short term Action Long term Action

Athlete with Concussion ABC, Stop participation SCAT-5 Neurological Prevent Post Concussion Syndrome
Cervical spine assessment Symptomatic recovery Neuropsychological testing
Assess if hospital transfer is required Neurovestibular rehab

Runner with Midfoot pain Assessment to rule out Navicular Staging of the stress fracture Rehab and Return to play
stress fracture Non-operative Rx Address risk factors
N-Spot Operative Rx
Stop running
Adolescent with heel pain Assessment Initial treatment Biomechanical correction
POLICE Activity modification Training loads
Education
Rower with Chest pain Stop activity Healing of the fracture Correct biomechanics
Initial assessment
Bone scan/CT
Staging of the stress #

Wrestler with skin rash Assessment Wait for healing of the lesions Personal and Equipment hygiene
Differentiate form other infection Anti-viral Education
Stop participation Team assessment Prevention of recurrence
 Case 6
Parathlete
with
hypertension
Spinal cord Injury
wheelchair racing athlete

2 hours before the race–

red flushed face and
headache
Autonomic dysreflexia- T6 and above injury
• Pounding headache (caused by the elevation in blood pressure)
• Sweating above the level of injury
• Restlessness
• Flushed (reddened) face
• Red blotches on the skin above level of spinal injury
• Cold, clammy skin below level of spinal injury

Examination:
Sharp elevation of blood pressure
Bradycardia

Pressure sores
Distended bladder, blocked catheter
Constipation, faecal impaction
Video- Disclaimer
From You tube in the Public domain
Source is identifiable on the video and only for Educational use.
BOOSTING
Autonomic Dysreflexia and Boosting: Non-pharmacological
doping in disability sport
If BP >180 mm Systolic, retest after few minutes
- If still high: Athlete is disqualified
- No sanctions, but IPC Ethical committee
- Disqualification is to prevent serious injury
Including death of the athlete
Management:
Remove the patient from competition
Sit the patient up
Examine for the common causes - bowel and bladder
-Insert a catheter if one is not in use
Anti-hypertensive if systolic blood pressure >150mmHg
(Nifedipine 10mg rapid release or GTN)- Rule out
VIAGRA
Avoid beta blockers - may cause peripheral
vasoconstriction resulting in prolonged hypertension
Low threshold to transfer to hospital
 Prevention Strategies
TRAINING LEVEL
- Education: recognize symptoms early ATHLETE LEVEL
- rewards and Punishment

- Bowel and bladder management

- Avoid constipation
EQUIPMENT
-Regular catheterization (avoid bladder distension)
- Wheel chairs
- Monitor for UTI’s
- no sharp areas - Avoid pressure areas

- padding - Self monitoring of blood pressure

 SUMMARY
Condition Immediate action Short term Action Long term Action

Athlete with Concussion ABC, Stop participation SCAT-5 Neurological Prevent Post Concussion Syndrome
Cervical spine assessment Symptomatic recovery Neuropsychological testing
Assess if hospital transfer is required Neurovestibular rehab

Runner with Midfoot pain Assessment to rule out Navicular stress Staging of the stress fracture Rehab and Return to play
fracture Non-operative Rx Address risk factors
N-Spot Operative Rx
Stop running

Adolescent with heel pain Assessment Intial treatment Biomechanical correction

POLICE Activity modification Training loads
Education

Rower with Chest pain Stop activity Healing of the fracture Correct biomechanics
Initial assessment
Bone scan/CT
Staging of the stress #

Wrestler with skin rash Assessment Wait for healing of the lesions Personal and Equipment hygiene
Differentiate form other infection Anti-viral Education
Stop participation Team assessment Prevention of recurrence

Parathelte with HTN Sit upright Follow-up Education

Remove causative factor Ethical concerns Removal of risk factors
GTN/Nifedipine
 References
1. AIBA 2016 Medical Handbook For ring side doctors Version 2016.07.13
2. Australian Football League, Australia www.afl.com.au
3. https://www.acsep.org.au
4. https://www.sma-australia.com.au
5. https://ais.gov.au
6. Australian Institute of Sport and Australian Medical Association Concussion in Sport Position Statement .Dr Lisa
Elkington, Dr Silvia Manzanero and Dr David Hughes Australian Institute of Sport . Updated November 2017
http://www.acsep.org.au/content/Document/34304_Concussion_Position_Statement_2017.pdf
7. Shakked RJ, Walters EE, O’Malley MJ. Tarsal navicular stress fractures. Curr Rev Musculoskelet Med (2017)
10:122–130
8. Elengard T, Karlsson J, Silbernagel KG. Aspects of treatment for posterior heel pain in young athletes. Open Access
J Sports Med. 2010; 1: 223–232
9. Evans G and Redgrave A. Great Britain Rowing Team Guideline for Diagnosis and Management of Rib Stress Injury:
Part 2 – The Guideline itself. Br J Sports Med 2016;50:270–272
10. Rowing Australia https://rowingaustralia.com.au
11. Preventing spread of herpes Gladiotorum infection. Minnesota Department of health Infection control: Fact
sheet
12. Herpes Gladiotorum Position Statement and Guidelines NFSHA- Sports Advisor Committee
13. Blauwet CA, Benjamin-Laing H, Stomphorst J et al. Testing for boosting at the Paralympic games: policies, results
and future directions. BJ Sports Med 2013;47:832–837
 THANK YOU

Questions?

wcsachin@yahoo.com @wcsachin sachinkhullar