Treatment and Prevention of Sports Injuries

Acute treatment protocol - PEACE

• P (Protect). Unload or restrict movement during the first (1-3) days after the injury to reduce bleeding and prevent further damage to the site of injury.
• E (Elevate). Elevate the injured limb or other body part, if possible, higher than the heart to promote interstitial fluid flow away from the site of injury.
• A (Avoid anti-inflammatory modalities). To the extent possible, avoid use of anti-inflammatory factors in the initial treatment.
  • Pharmacotherapies affecting the inflammatory process, such as NSAIDs, may hinder the healing process of tissues through preventing the beneficial effects of inflammatory reaction on tissue healing. In bone fractures, for example, use of NSAIDs slows down ossification.
  • The evidence on the efficacy of cold therapy in the treatment of acute tissue injuries is scarce and partly controversial. Prolonged cold therapy may hinder the progress of inflammatory reaction and hence slow down the repair process.
• C (Compress). Mechanical compression around the injured tissue reduces swelling and interstitial bleeding.
• E (Educate). Encourage the patient to an active and self-directed rehabilitation. Passive treatment modalities are rarely beneficial in the treatment of an acute injury. Avoid over-treatment and encourage the patient to get a grip on the treatment process themselves. Provide the patient with realistic expectations concerning the recovery time.

Treatment protocol after the acute phase - LOVE

• L (Load). Replace rest with optimal loading.
  • The new recommendation emphasizes that loading should be started and normal activities resumed as soon as symptoms allow. Optimal loading without exacerbating pain promotes healing of tissues through movement (mechanotransduction).
  • Normal training often needs to be replaced with alternative exercises so that the developing scar would be as small and strong as possible.
• O (Optimism). Support optimistic patient expectations towards healing while at the same time remain realistic concerning the recovery time. Catastrophization, depression and fear of movement are associated with worse outcome during recovery from injury.
• V (Vascularisation). Support the formation of new blood vessels.
  • Aerobic exercise started a few days after injury increases blood flow in injured tissues, promoting neovascularization and hence healing of tissues. Aerobic exercise and early mobilization improve physical function and reduce the need for pain medication.
• E (Exercise). Do physical exercises that prevent new injuries. Start therapeutic training early, restoring mobility, strength and proprioception.
  • Pain should be avoided and the description of pain sensation should be used as a guide for exercise progressions.
  • Therapeutic exercise that supports the neuromuscular system prevents the occurrence of new injuries.
  • Neglecting active rehabilitation leads to poor orientation of scarring and new tissue and to poor strain tolerance, increasing the risk of the injury recurring.

Symptoms and signs

• At first, pain is only present after exercise, particularly if the knee is bent for a long period. Later on, pain is also present during exercise, particularly when jumping, running or deep squatting. In the most advanced stage, knee pain is present at rest.
• Palpation will reveal point tenderness at the inferior patellar pole, and occasionally also more distally at the patellar tendon. Diagnosis can in most cases be made on the basis of history and physical examination alone, and imaging studies are only indicated in unclear or persistent cases.
  • In chronic patellar tendinitis, x-rays may show a bone spur or a loose bone fragment at the inferior patellar pole. Ultrasonography and magnetic resonance imaging (MRI) often detect local tissue oedema, macroscopic tendon damage and a possible area of focal degeneration.

Treatment

• Initially rest and anti-inflammatory analgesics. The painful area can be gently rubbed with an ice cube or NSAID gel.
• Running and jumping on hard surfaces and squats should be avoided. The patient should be taught to allow the knees and hips bend slightly when landing from a jump.
• Other potentially beneficial forms of treatment:
  • Eccentric anterior and posterior thigh exercises for several weeks. Training slowly, using heavy weights, increasing the cross-sectional tendon area and the stress tolerance of tendons has proved most effective. An exercise session should last 90 minutes, and exercises should be performed three times weekly for 12 weeks. Painful exercising, such as running, should be avoided during that period.
  • If symptoms persist, control of the lower torso and alignment of the lower limb should be examined and guidance provided for the necessary exercises. Control of the alignment of the lower limbs can be improved through exercises improving the neuromuscular system. Exercises for hip abductor and external rotator muscles are particularly effective in correcting deficiencies in the alignment of the lower limbs.
  • Stretching exercises for the quadriceps muscle and the patellar tendon may prove to be beneficial.
• A glucocorticoid/anaesthetic injection may be administered in persistent cases to the posterior surface of the tendon's upper insertion site (using a lateral approach to insert the needle behind the tendon). Repeated injections should be avoided as they may promote tendon degeneration. No more than a total of three injections should be administered, and an interval of 2 weeks between the injections is recommended. Injections are not recommended for growing children.
• Physical therapy (ultrasound, laser, electrotherapy) is equivalent in efficacy to placebo treatment.
• Occlusion of peritendinous vessels, i.e. sclerotherapy, and platelet-rich plasma are ineffective forms of treatment.
• Chronic patellar tendinitis can be treated surgically, usually by longitudinally excising the base of the involved tendon followed by debridement of degenerated tendon tissue and possible calcification from its inferior surface.

Symptoms and findings

• At first, pain may only be present after exercise, later on also during exercise. In the most advanced stage, lower leg pain is present at rest.
• The diagnosis of shin splints is based on typical pain symptoms at the medial edge of the tibia and tenderness on palpation of the painful area. Osteogenic pain is sharp and restricted to a small area. Pain originating from the fascia and tendons is located in a larger area at the medial edge of the tibia, and its intensity and location vary. Pain from the fascial compartment is a dull ache of the claudication type.
• In the doctor's office, alignment of the patient's lower limbs and ranges of joint motion should be checked. Control of the lower torso and activation of hip abductor muscles can be indirectly assessed by one-leg squat and drop jump tests. A hand dynamometer can be used to assist in measuring strengths.
• Imaging studies generally offer no help in diagnostics, and they are usually not indicated. In some cases, x-rays or MRI may be necessary to exclude a tibial stress fracture Stress Fractures. The MRI findings in a tibial stress fracture may include a periosteal reaction on the tibial surface and bone marrow oedema.

Treatment

• The cornerstone of the treatment of shin splints is reducing and shifting the load. In the case of pain affecting the posterior lower leg, a heel strike gait pattern should be encouraged because this will reduce the load on plantar flexors of the ankle, shifting it more towards the knee and pelvis. In pain of the anterior lower leg, a forefoot strike gait should be encouraged.
• In the acute stage, the painful area can be lightly massaged with, for example, an ice cube or an anti-inflammatory analgesic gel (so-called shin splints massage). A course of anti-inflammatory analgesics may also be necessary.
• Complete rest is unnecessary. Alternative forms of exercise, such as exercising at a gym, cycling, swimming or aqua jogging can be recommended.
• The patient should be taught exercises for hip abductors and external rotators, and control of alignment of the lower limbs should be improved.
• As control of the lower torso and alignment of the lower limbs are improved, it is rarely necessary to start using support orthotics correcting the position and guiding movement. Nevertheless, orthotics can be used in thin-soled working and leisure-time shoes as shock absorbers and in cases where there is clear structural malposition in the foot or ankle area that cannot be otherwise controlled.
• Glucocorticoid/anaesthetic injections are not routinely used in the treatment of shin splints. Injections are not recommended for growing children.
• Physical therapy (ultrasound, laser, electrotherapy) has no place in the treatment of shin splints.
• Completely chronic shin splints may be managed with surgery, in which a single longitudinal incision is made along the deep leg compartment at the medial tibial edge (fasciotomy). See also Muscle compartment syndromes Muscle Compartment Syndromes.

Symptoms and findings

• The condition is most common in runners. At first, pain is only present after exercise, later on also during exercise, even when only walking. In the most advanced stage, pain around the Achilles tendon is present at rest.
• Palpation will reveal point tenderness either over the tendon itself or at its insertion site on the calcaneus. The tendon may be visibly thickened. Diagnosis can in most cases be made on the basis of history and physical examination alone, and imaging studies are only indicated in unclear or persistent cases.
  • X-rays may show a bone spur or loose calcium fragments within the tendon or its calcaneal insertion. Ultrasonography and MRI often detect peritendinous oedema, macroscopic tendon damage, an area of focal degeneration and, possibly, fluid in the retrocalcaneal bursa.

Treatment

• The cornerstone of the treatment is load reduction and load change. Initially, the patient should rest and a heel strike gait pattern should be encouraged because this will reduce the load on the Achilles tendon and other plantar flexors of the ankle, moving it more towards the knee and pelvis.
• In the acute stage, an anti-inflammatory analgesic as a course of 3-7 days. It is important to avoid all physical exertion/strain that causes pain.
• Calf and Achilles tendon stretches, as well as a short-term use of a heel wedge, may be beneficial.
• Calf muscle exercises for several weeks (e.g. calf raise and heel drop exercises)
• A glucocorticoid/anaesthetic injection around the tendon or into the bursa may be given in the acute or subacute stage. Later on, such injections will probably no longer be useful. Repeated injections should be avoided as they may promote tendon degeneration. No more than a total of three injections should be administered, and an interval of 2 weeks between the injections is recommended. Injections are not recommended for growing children.
• Physical therapy (ultrasound, laser, electrotherapy) has no place in the treatment of Achilles tendinitis. Occlusion of peritendinous vessels, i.e. sclerotherapy, and platelet-rich plasma are also ineffective forms of treatment.
• If symptoms persist, control of the lower torso and alignment of the lower limb should be examined and guidance provided for the necessary exercises. Exercises for hip abductor and external rotator muscles are particularly effective in correcting deficiencies in the alignment of the lower limbs.
• Chronic Achilles tendon problems can be treated with surgery. Several types of surgery are available including the excision of adhesions from around the tendon. Longitudinal tenotomy may also be performed to remove an area of focal degeneration from within the tendon. In chronic insertional tendinitis, depending on the findings, the retrocalcaneal bursa is removed, any tears are repaired, degenerated foci excised, and, as required, the calcaneal upper posterior angle is smoothed in order to minimise friction.

• A painful condition seen in runners caused by the sliding of the iliotibial band over the lateral femoral epicondyle when running leading to friction, which in turn causes tenoperiostitis between the tendon and bone.
• Iliotibial band syndrome may also be associated with irritation of the pinched synovial plica or bursa.

Symptoms and findings

• Lateral knee pain is characteristic. Pain usually starts during running and forces the person to stop running. The pain usually resolves at rest but will recur during running. The pain is often worse when running downhill.
• Physical examination findings are usually sparse, but tenderness is usually present over the iliotibial band at the lateral femoral condyle. Pain can sometimes be elicited if the patient bears his/her weight on a flexed knee.

Treatment

• Pain may persist for several months, but recovery is usually spontaneous without the need for surgery.
• Any sport that puts pressure on the knee region, particularly running, must be stopped until the condition improves. Anti-inflammatory medication (topical ointment or oral) may be necessary in the early stage. Glucocorticoid/anaesthetic injections have also been used. No more than a total of three injections should be administered, and an interval of 2 weeks between the injections is recommended. Glucocorticoid injections are not recommended for growing children.
• Core and pelvic muscle exercises are recommended in order to improve body control, lower limb position as well as technique. In particular, excercises of the abductors and external rotators of the hip are effective in correcting deficits in the lower limb alignment.
• The iliotibial band attaches proximally to the tensor fasciae latae muscle and the gluteus maximus muscle. If these muscles are tight, massage or stretching can be used to loosen them.
• Rare, persistent cases may require surgical management, which is performed in accordance with the findings.

• A microscopic or macroscopic tear of the tendon fibres superior to the inguinal ligament at the common insertion site for the rectus abdominis muscle, the internal oblique abdominal muscle and the transversalis fascia at the pubic tubercle (the upper lateral position).
• Despite its name, the injury does not result in medial inguinal hernia even though it occurs in the same area.

Symptoms and findings

• At first, groin pain is present only during quick movements and when straining. Abdominal muscle work produces pain.
  • Pain may radiate, not only to the groin and lower abdomen, but also to the perineum, thigh, lower back, sacrum and buttocks.
• Point tenderness is noted on palpation of the area superior to the inguinal ligament superolaterally to the pubic bone.
• Muscle compliance is limited and in some cases a local muscle spasm is noted.
• Ultrasonography findings are usually normal. MRI should be requested by a specialist in preparation for a surgical intervention. MRI findings include local tissue oedema and macroscopic tendon damage as well as atrophy of the abdominis rectus muscle on the affected side.
• Differential diagnosis should consider the possibility of more common problems affecting the groin area of athletes, such as tears at other tendon insertion sites and enthesitis, inflammation of the pubic symphysis (osteitis pubis), hip stress fractures and bursitis.

Treatment

• Initially rest and anti-inflammatory agents. Pain-inducing quick movements and jumps should be avoided.
• The length of the rest period depends on the sport in question and the severity of symptoms. A rest period of 2-4 weeks from pain-inducing exercises is indicated in the acute phase.
• After the acute phase, rehabilitation planned and supervised by a physiotherapist should be tried.
• Chronic sports hernia can be managed surgically. The aim of surgical intervention is to debride and repair both the tendon complex and the insertion site for the inguinal ligament at the symphysis as well as to strengthen the area with a mesh repair.
  • The recovery from surgery will take about 3 weeks. The strength and mobility of muscles must have returned to normal before intense training is recommenced.

Treatment

• The aim of treatment is to control the epicondyle pain and inflammation at as early a phase as possible.
  • Acute pain is treated with an ice pack and anti-inflammatory analgesics Non-Steroidal Anti-Inflammatory Drugs (Nsaids) for Treating Lateral Elbow Pain.
  • In general, glucocorticoid injections are not recommended for the treatment of epicondylitis because they increase the recurrence of the pain within a 3-12 month follow-up period despite providing good short-term (less than 6 weeks) pain relief. Glucocorticoid injections are not recommended for growing children.
  • When pain occurs, a break of 1-2 weeks from racket and throwing sports is usually indicated. Moreover, any occupational strain on the arm muscles should be modified: for example, using the computer mouse with the other hand may be necessary for a few months.
  • After the acute phase, the arm muscles are stretched and strengthened using light 1-5 kg weights or a resistance elastic band. Eccentric exercises are also recommended for the treatment of epicondylitis (drop exercises where the concentric phase is omitted, e.g. a weight held in the affected hand holding a weight is assisted by the unaffected hand to its start position from where it is allowed to drop and, for example, hang off the table).
  • A strap/brace that provides slight compression to the muscles of the painful side may promote healing. The strap/brace is applied so that it reaches to about 5 cm from the distal end of the elbow epicondyles. Tennis elbow support straps which incorporate a small air cushion have proved to be the most effective in practice. Short-term use of a wrist splint has been found to be as beneficial as a tennis elbow support strap.
  • Surgery should be considered in recalcitrant cases that have persisted for at least six months, when other properly structured and supervised treatment modalities have been tried.
  • As soon as problems emerge it is recommended that the sports technique is checked and corrected by an appropriate sports professional.