Ballet

Ballet is a very demanding activity that may be associated with delayed menarche and eating disorders in female dancers (Chapter 682). Acute injuries are most often of the lower extremities. As with any repetitive activity, overuse injuries are likely; the key is to make the correct diagnosis and also consider the kinetic chain dysfunction that might have contributed to that injury. A dancer might have an unrehabilitated ankle sprain, causing favoring of that leg, leading to a stress fracture of the contralateral tibia. Foot problems include metatarsal stress fractures, subungual hematomas, calluses and bunions, sesamoiditis, and plantar fasciitis.

Going en pointe is a question that young ballet dancers and their parents may ask. An average age to go en pointe is 12 yr. A function test should be part of that decision: If the child can go en pointe, holding the position without pain and not appearing unstable and weak, then he or she is probably ready to try dancing en pointe.

Ankle problems include anterior and posterior impingement syndromes because of the extremes of range of motion in grand plié and en pointe, respectively. Hip problems include the medial snapping hip syndrome, caused by the iliopsoas tendon’s riding over the anterior hip capsule, and tendinosis of the piriformis, iliopsoas, and rectus femoris. The piriformis syndrome occurs because of the repetitive external hip rotation required in ballet and can manifest as buttock pain and sciatica.

Wrestling

Wrestlers have great fluctuations in weight to meet weight-matched competition standards. Such fluctuations are associated with fasting, dehydration, and then bingeing.

Wrestling holds can produce injury owing to various torques or forces applied to the extremities and spine; wrestling throws with subsequent falls can produce concussions, neck strain, or spinal cord injury. The 2 most common sites of injury are the shoulder and knee. “Stingers” and “burners” are due to a brachial plexopathy (see Football).

Shoulder subluxation is common. Patients are often aware of their shoulder’s slipping in and out (Chapter 679.2). Hand injuries are usually not severe and include recurrent metacarpophalangeal and proximal interphalangeal sprains. Treatment of hand injuries includes splinting and taping.

Knee injuries are common and potentially serious and include prepatellar bursitis, medial and lateral sprains, and medial and lateral meniscus tears (Chapter 679.6). Prepatellar bursitis is caused by acute or recurrent traumatic impact to the mat. Swelling occurs over the patella, and patients have no limitation of motion except full flexion. If the skin has been broken, septic bursitis has to be considered. The physician must try to distinguish traumatic from infected bursitis, which can require aspiration of the bursa. Treatment of traumatic bursitis includes protective padding, ice, nonsteroidal anti-inflammatory drugs (NSAIDs), and occasionally aspiration if flexion is impaired. Rarely bursectomy is needed if there are several recurrences.

Dermatologic problems include herpes simplex (herpes gladiatorum), impetigo, staphylococcal furunculosis or folliculitis, superficial fungal infections, and contact dermatitis. The first two are contraindications to wrestling until the infection is no longer contagious. If herpes infections recur, suppressive oral antiviral agents should be used.

Football

Football continues to be the sport with the highest number of injuries, one of the greatest number of participants, and one of the sports with a high injury rate. In terms of the severity of injury, defined as days lost per injury, the average injury in football is less severe than in many other sports. Most of the injuries are sprains, strains, and contusions that, once treated, appropriately result in minimal time away from football.

Although the majority of catastrophic sports injuries in the USA have occurred in football, severe injuries are rare. Catastrophic is defined as a fatal injury or a severe injury with or without permanent severe functional disability. Disabling injuries include cervical spine and cerebral injuries.

Head and neck football injuries include concussion, neck sprain, and brachial plexopathy. The latter is referred to as a “stinger” or “burner.” Lumbar spine injury manifested as low back pain can indicate spondylolysis. Shoulder trauma can cause glenohumeral dislocation, the majority of which are anterior dislocations, acromioclavicular separations, and clavicular and humeral fractures.

Contusions to the arm and thigh muscles are common and can result in large hematomas if not treated aggressively. Assuming that there is no fracture, treatment includes ice and compression during most waking hours for the first few days to limit the expansion of the hematoma and then doing pain-free strengthening and stretching exercises until baseline function is achieved. Then return to contact can be approved. When the hematoma is allowed to persist and especially if there is a second hematoma into the first, myositis ossificans can develop.

Knee injuries are the most common musculoskeletal complaint at the time of preseason examinations. Knee injuries are discussed in Chapter 679.6.

Ankle sprains occur, and the risk of reinjury may be reduced by rehabilitation and use of a lace-up ankle brace. Turf toe, a sprain to the first metatarsophalangeal joint, is caused by forceful dorsiflexion while playing on artificial turf in soft, lightweight, flexible shoes. Treatment of turf toe includes ice, NSAIDs, an orthotic to limit extension of the great toe, and rest. Turf toe can be a season- or career-limiting injury.

Ice Hockey

Hockey is a collision sport associated with injuries caused by the puck or the stick hitting the player or by body contact with other players, the ice, or the boards, producing contusions, lacerations, fractures, sprains, or concussions. The risk of injury is reduced by proper equipment (helmets with face masks) and enforcement of the rules regarding dangerous body contact (checking from behind, high sticking, slashing, and fighting).

Specific hockey injuries include ankle sprains (dorsiflexion, eversion, and external rotation in contrast to the usual sprain of inversion in other sports), hip adductor strain, osteitis pubis, and various shoulder injuries from body contact. Shoulder injuries include acromioclavicular sprain, dislocation, and clavicular fractures. The most serious injuries are to the head and neck.

Basketball and Volleyball

Common maneuvers of these two sports include using a ball with one’s hand, jumping, pivoting, running, and sudden stopping, which increase the risks of ankle, knee, and finger injury.

Knee overuse injuries include patellar tendinosis (jumper’s knee) and traction apophysitis (Osgood-Schlatter disease) (Chapter 669.4). As with other jumping sports, acute ligament sprains (medial collateral with or without anterior cruciate ligaments) can occur.

Ankle sprain is the most common injury and is usually caused by inversion with plantar flexion, placing the lateral ligaments at high tension. An avulsion fracture of the base of the 5th metatarsal at the insertion of the peroneus brevis tendon is another sequela of inversion ankle injuries. Achilles tendinosis is a common overuse injury. Foot pain may be due to retrocalcaneal bursitis, posterior tibial tendinitis, accessory tarsal navicular, calcaneal periostitis, plantar fasciitis, stress fracture of the tarsal navicular, Jones stress fracture of the 5th metatarsal, sesamoiditis, blisters, subungual hematoma, and paronychia.

Running

Running problems are usually due to an overuse injury related to muscle imbalance; a minor skeletal deformity; or poor flexibility, strength, endurance, or proprioception. With each step while running, the foot impact ranges from 3 to 8 times the athlete’s body weight. Most problems are due to errors in training when the runner increases the distance or intensity of training too rapidly. Minor variations (malalignment) in anatomy, which do not cause problems at rest, can predispose to injury at specific sites (e.g., patellofemoral stress). Muscle fatigue, environmental temperature, and running surface (grass vs unyielding concrete) also contribute to injuries. Prevention of injuries is possible by muscle-strengthening exercises for previous injuries. Using good-quality running shoes that match an athlete’s foot type is an essential first step. Gender-specific shoes are important because girls generally have a narrower rearfoot. Those who severely overpronate need a motion control shoe for maximal rearfoot and arch support in the midsole. Those who mildly overpronate need a stability shoe that has extra support in the medial midsole and some midsole cushion. Those who supinate need a cushioned shoe with more shock absorption in the midsole, more curved last, and minimal arch support.

Stress Fractures

Stress fractures of all bones of the lower extremity can occur in runners. Stress fractures of the femoral neck, inferior pubic rami, subtrochanteric area, proximal femoral shaft, proximal tibia, fibula, navicular, metatarsal, sesamoid, and calcaneal apophysis can occur. The most common are in the metatarsals, the tibia, and the fibula. The most worrisome in terms of risk of nonunion are in the anterior proximal tibia, the femoral neck, and the tarsal navicular. Muscle strains often affect the hamstrings, followed by the quadriceps, hip adductors, soleus, and gastrocnemius muscles. Tendinitis involving the tendon and its sheath is common in the Achilles tendon, followed by the posterior tibial, peroneal, iliopsoas, and proximal hamstring tendons. Achilles tendinosis develops chronically, initially might get better during a run, is characterized by tenderness and crepitance if acute and nodularity if chronic, and must be distinguished from retrocalcaneal bursitis.

Treatment includes identifying the underlying cause and temporary abstinence from running (begin cross-training), a heel lift, Achilles tendon stretching, and NSAIDs.

Runner’s Knee

Anterior knee pain is usually due to patellofemoral stress syndrome (runner’s knee), which results from excessive dynamic, usually lateral, motion of the patellar tendon in relationship to the femoral intracondylar groove.

Treatment includes stretching of the quadriceps and hamstring muscles and often the iliotibial band. Strengthening exercises should include the quadriceps, hips, and core muscles. Ice and relative rest are also helpful. Foot orthotics may be indicated if there is no improvement with the aforementioned treatment. Posterior knee pain can be caused by gastrocnemius strain, posteromedial pain may be due to proximal tibial stress fractures or semimembranosus or semitendinosus tendinitis, and lateral knee pain may be due to iliotibial band syndrome and popliteus tendonitis.

Iliotibial Band Syndrome

Iliotibial band syndrome may be a combination of bursitis and tendinitis owing to mechanical friction of the band (an extension of the tensor fasciae latae) over the lateral femoral epicondyle.

Shin Splints

Shin splints, or medial tibial stress syndrome, is a descriptive term for diffuse pain over the distal medial tibia and should be distinguished from tibial stress fractures and chronic compartment syndromes (Chapter 679.7). Medial tibial stress syndrome usually occurs in new runners with overpronation.

Treatment includes running on soft surfaces, proper shoe selection, and, possibly, orthotics, NSAIDs, and relative rest (or cross-training).

Chronic compartment syndromes involve any of the muscle compartments with the most common being the anterior compartments. There is typically poorly localized throbbing pain that does not occur until about 10-15 minutes into the run. In the office the physical exam is usually normal. Diagnosis is made by measurement of increased intracompartmental pressures at rest or during exercise.

Plantar Fasciitis

Plantar fasciitis is an inflammation of the supporting structure of the longitudinal arch, due to repetitive cyclic loading with foot strike. Pain increases with the first step out of bed in the morning and with running and is located on the medial aspect of the heel. It is associated with wearing old shoes or shoes with poor arch support. Treatment includes calf stretching, proper shoes, night splints, corticosteroid injection, relative rest, and ice massage of the heel. Calcaneal stress fracture must be considered, especially in the amenorrheic distance runner.

Soccer

Injuries in soccer include any of the running injuries as well as abrasions, contusions, muscle strains, and ligament sprains (ankle, knee), due partly to body-to-body contact, falls, running, and kicking. Hip problems include the “hip pointer” (iliac crest contusion), iliac crest apophysitis, and chronic groin pain (muscle strain, hernia, osteitis pubis). Femoral neck stress fractures, slipped femoral capital epiphysis, and avulsion fractures of the pelvis or femur are to be considered in the differential diagnosis yet are unusual causes of hip pain. All other lower and upper extremity injuries can occur in soccer.

Concussions occur commonly in soccer. Concussion can lead to neurocognitive dysfunction, and concussions occur in soccer due to contact between players, player and goal post, and player and ground. The American Academy of Pediatrics recommends that youth soccer participants minimize heading the ball until more is known about the risks in young children. Proper heading technique should be taught in youth soccer: On long kicks, the receiving player traps the ball with the chest or leg, not the head; defenders kick the ball about 5 ft in front of their midfielders or forwards so the latter have to come to the ball and trap with their legs; players avoid heading the ball backward toward the goal (with cervical extension); referees, as with all sports, keep the game under control and penalize dangerous play; and guidelines for returning to play after a concussion should be followed.

Tennis

Lower extremity injuries occur twice as often as upper extremity injuries in tennis, and overall injury rates are similar for boys and girls. Common areas of injury in tennis include muscles and tendons of the elbow, shoulder, back, wrist, and abdomen. The risk of injury is increased by increased training; by unrehabilitated injuries with resultant deficits in flexibility, strength, and endurance; and by poor technique. Acute injuries of the lower extremities include ankle, knee, lower leg, and groin strains. Overuse injuries of the back and lower and upper extremities occur. The lower extremity injury patterns are related to the fact that for accomplished players there are an average of eight direction changes per point, creating eccentric and concentric loads on the lower extremities. In the back, injuries are related to the marked and rapid load and direction change associated with serving, and the shoulder, elbow, and wrist are moving at velocities of up to 1,700, 900, and 350 degrees/sec, respectively, in a repetitive fashion.

Injuries can be related to improper equipment, such as a racquet that is too big, or to trying to learn techniques, such as hitting with top spin or with power before proper coordination and technique in basic strokes have been established. Overuse injuries include stress fractures of the humerus, ulna, and metacarpals and traction apophysitis of the calcaneus, tibial tubercle (Osgood-Schlatter disease), and medial humeral epicondyle.

Rotator cuff tendinosis is caused by repetitive overuse and may be related to anteroposterior glenohumeral instability. Subluxation of the glenohumeral joint may also be present. Biceps tendinosis can manifest as anterior shoulder pain.

Tennis elbow, or lateral epicondylitis, is due to repetitive overload of the wrist extensor-supinator mechanism, especially the extensor carpi radialis brevis (Chapter 679.3). Medial epicondylitis is caused by repetitive overload of the wrist flexor-pronator muscle groups. This can secondarily involve the medial collateral ligament; however, the ligament is uncommonly the site of the primary injury. Medial epicondylar apophysitis may be associated with ulnar nerve dysfunction. Olecranon apophysitis is similar to Osgood-Schlatter disease and is marked by pain at the olecranon with elbow extension.

Wrist problems include an enlarged dorsal ganglion cyst, radiocarpal joint capsular (impingement) synovitis, degenerative attrition (tears) of the triangular fibrocartilage complex, and fracture of the hook of the hamate.

Basic treatment includes relative rest, analgesics, application of ice, rehabilitation, learning proper mechanics, using properly sized racquets, protective counterforce bracing (elbow, wrist), strengthening exercises, and gradual return to tennis. Corticosteroid injections into the extensor-supinator muscle group for tennis elbow are not recommended because the outcome at 1 yr is poorer than for those treated with rehabilitation.