Sports injuries

This article focuses on injuries that are commonly associated with sporting activities, but they can also occur at work or during activities of daily living. Sports injuries are usually the result of direct trauma or a sudden increased load on the joints, ligaments, and/or muscles. Acute joint and ligament injuries typically result from nonphysiological movements in the joints (e.g., excessive supination of the ankle). Treatment of acute sports injuries usually follows the POLICE principle (protection, optimal loading, ice, compression, and elevation). Definitive therapy depends on the extent of the injury (e.g., the presence or absence of fractures) and ranges from immobilization of the affected region (e.g., casts, braces, supportive wraps) to surgical repair. Compression neuropathies, especially of the peripheral nerves of the upper extremity, are commonly associated with sport. In most cases, compression neuropathies can be treated with conservative management (e.g., rest, activity modification, physical therapy); surgical decompression may be considered for those with symptoms that are refractory to conservative management.

The following are commonly associated with sports, however, they also occur during other kinds of activity:

• Covered in this article
  • Ankle sprains
  • Patellofemoral pain syndrome (PFPS)
  • Medial tibial stress syndrome (MTSS)
  • Knee tendon injuries
    • Quadriceps tendon rupture
    • Patellar tendon rupture
  • Muscle injuries
    • Muscle strain
    • Muscle contusion
    • Delayed onset muscle soreness
  • Compression neuropathies in sport
• Covered in other articles
  • Finger injuries
  • Meniscal tears
  • Knee ligament injuries
  • Achilles tendon rupture
  • Ankle fracture

Diagnosis ^[1]

• Clinical evaluation
  • Examine the extremity for open injuries or joint deformity.
  • Assess active and passive range of motion (ROM).
  • Identify areas of tenderness.
  • Test for ligamentous injury with stress testing.
  • Assess major muscle group strength.
  • Perform a thorough neurovascular examination.
• Imaging
  • Indicated if there is a concern for fracture and/or dislocation.
  • Protocols and guidelines can reduce unnecessary testing.
    • Ottawa ankle rules
    • Ottawa knee rules
  • The threshold to obtain advanced imaging, e.g., MRI, is often lower for professional or elite athletes.

Treatment by injury phase ^[2]

The treatment strategy depends on the pathophysiological phase of the injury.

• Acute ^[2]
  • Acute local inflammation
  • Clinical features: warmth, erythema, swelling, reduced function
  • Duration: typically 1–3 days
  • Treatment goals include protecting injured tissue and reducing inflammation.
• Subacute ^[2]
  • Chronic local inflammation and impaired tissue strength
  • Clinical features: limited ROM, pain
  • Duration: days to months
  • Treatment goals include increasing ROM, increasing strength, and improving proprioception.
• Chronic ^[2]
  • Chronic local inflammation and/or excessive collagenous response to the original injury
  • Clinical features: pain and stiffness at rest that improves with activity
  • Treatment goals include avoiding aggravating activities, maintaining ROM, and reducing chronic inflammation.

POLICE principle ^[3][4]

• Protection; : immobilization (e.g., with a brace, crutches) after a brief period of relative rest to prevent further injury
• Optimal Loading
  • Frequent movement of the affected limb within a pain-free range in order to restore function
  • Optimal loading depends on injury location and severity.
• Ice
  • Cool the injured area immediately. ^[5][6]
  • Apply an ice pack for ≤ 30 minutes each session; repeat as needed for pain control and swelling.
  • To reduce the risk of frostbite, do not apply ice directly to the skin.
• Compression
  • Use an elastic compression bandage.
    • Apply elastic bandage distal to the injury and continue proximally
    • A change in the character of pain (e.g., sharp to throbbing pain) may indicate tissue ischemia; remove, assess, and reapply the dressing.
  • Taping (tape bandages) should not be used during the first 12–24 hours.
  • Continue compression as long as there is a risk of swelling. ^[2]
• Elevation: Maintain the injured area above the level of the heart.

RICE principle

• RICE = Rest, Ice, Compression, Elevation
• No longer recommended because early mobilization has been shown to improve postinjury function ^[2]

Rehabilitation ^[7]

The transition from acute care to performance care often involves multiple caregivers, especially for elite athletes and/or major injuries.

• Consider early referral to a sports medicine clinic for comprehensive care.
• Physical therapists can assist with acute care, restoration of motion, and improved neuromuscular coordination.
• Medically directed strength and conditioning programs may be necessary to restore full performance.

Activity modification for athletes ^[1][8][9]

General principles

• Premature return to full activity can worsen acute and overuse injuries, which risks prolonging disability.
• Adherence to activity restriction can be challenging, especially for patients who are highly motivated to continue their sport.
• Consult a sports medicine specialist or the athlete's team physician, whenever available, to guide the activity modification plan.
• Activities likely to exacerbate the injury are best avoided.
• Exercises that maintain tone, ROM, and flexibility of unaffected muscles, bones, or joints are typically safe to continue.
• A gradual return to activity is typically preferred.

Return to play (RTP)

RTP decisions are complex and involve input from healthcare providers, the patient, and parents or guardians (when applicable).

• Criteria for RTP include:^[1][8][9]
  • The status of acute or chronic injury makes further harm unlikely.
  • The sport-specific function of the injured body part has returned.
  • The individual can perform safely (may require a brace, orthotic, or equipment modification).
  • Overall musculoskeletal, cardiovascular, pulmonary, and psychological functions have been restored.
  • Participation does not put individual or other participants at risk.
  • Local and/or governing body regulations are fulfilled.
• Minor injuries: RTP decision can be made on an individual basis by experienced general care providers.
• Major injuries: RTP decisions are best made by sports medicine specialists.

Definitions ^[10][11]

• Lateral low ankle sprain: a sprain of ≥ 1 of the following lateral ligaments.
  • Anterior talofibular ligament (ATFL): most commonly affected ^[10]
  • Calcaneofibular ligament (CFL)
  • Posterior talofibular ligament (PTFL)
• Medial low ankle sprain: a sprain of the medial (deltoid ligament) complex which connects the medial malleolus to the talus
• High ankle sprain (syndesmotic ankle sprain): a sprain of the syndesmotic ligaments that connect the tibia and fibula in the lower leg (less common)

Etiology ^[10][11][12]

• Supination injury: excessive inversion of the ankle joint
  • Typically injures the ATFL and other lateral ligaments (CFL, PTFL)
  • The anterior inferior tibiofibular ligament is most commonly involved in high ankle sprains.
• Pronation injury: excessive eversion of the ankle joint causes a sprain of the medial deltoid ligament

In supination injuries, the Anterior TaloFibular ligament Always Tears First.

The most common cause of an ankle sprain is a forceful inversion of the ankle that damages the lateral ligament.

Classification ^[10][11][12]

• Grade I: no macroscopic changes
• Grade II: partial tear
• Grade III: complete tear

Clinical features ^[10][11][12]

• Soft tissue swelling
• Limited ROM at the ankle joint
• Tenderness over the sprained ligament
• Increased joint laxity and a prominent talus compared to the uninjured ankle
• Impaired weight-bearing and/or antalgic gait
• Hematoma may be visible

Diagnosis ^[10][11][12]

Ankle sprain is a clinical diagnosis.

Clinical evaluation

• Neurovascular examination: Examine for peroneal nerve injury (can occur with high ankle sprains).
• Ligament integrity tests
  • Anterior drawer test of the ankle
    • The tibia is held fixed with the knee and ankle at 90° and the foot is grasped behind the heel and pulled in an anterior direction.
    • Anterior translation or laxity suggests ATFL rupture.
  • Talar tilt test: Supination between the talus and tibia > 25° suggests CFL rupture.
  • Kleiger external rotation test: can help identify high ankle sprain

Ottawa ankle rules

• Used to assess whether x-rays for ankle and midfoot injuries are necessary to identify fractures. ^[13]
• Ankle x-rays are typically indicated for distal malleolar tenderness and/or inability to bear weight immediately after the injury or at the time of evaluation.
• For detailed criteria, see “Ottawa foot and ankle rules” in “Ankle fractures.”

Imaging ^[4]

• If initial x-rays are indicated (e.g., to rule out fracture or dislocation), obtain anteroposterior, lateral, and mortise views of the ankle.
  • X-rays may appear normal or show evidence of soft-tissue swelling around the medial and/or lateral malleoli.
  • See “Ankle fracture” for other abnormal findings.
• Consider MRI extremity for persistent symptoms and/or chronic ankle instability

Differential diagnosis ^[10]

• Ankle fracture
• Cuboid syndrome
• Osteochondral lesion

Treatment ^[10][11][12]

• Apply the POLICE principle.
• Consider NSAIDs.
• Mild to moderate sprains: Provide functional support (e.g., ankle brace) for 4–6 weeks.
• Severe injuries: Immobilize the ankle.
  • A duration of ≤ 10 days is recommended. ^[11][12]
  • Grade II sprain: lower extremity splint or walking boot
  • Grade III sprain: Consider a short leg cast. ^[14]
• Refer the following to orthopedic surgery: ^[14]
  • Symptoms that do not resolve with conservative management
  • Severe grade III lateral ankle sprains
  • Medial ligament (deltoid ligament) disruption
  • High-grade syndesmotic ankle sprain
  • Chronic ankle instability

The majority of lateral ankle sprains can be managed without surgery. ^[14]

Prognosis

• Full recovery is likely, but recovery time is related to sprain severity. ^[10]
• Chronic ankle instability and/or persistent symptoms are common. ^[11]
• Proprioception and balance training prevent recurrent sprains. ^[11][12]

Background

• Definition: A syndrome of pain behind or around the patella that is aggravated by weight bearing on a flexed knee. ^[15]
• Epidemiology ^[16][17][18]
  • One of the most common causes of anterior knee pain
  • Common in young athletes
  • ♀ > ♂
• Etiology ^[16][17][18]
  • Overuse
  • Malalignment of the knee joint

Clinical features ^[16][17][18]

• Retropatellar or peripatellar pain worsened by:
  • Flexion of the knee while weight-bearing, e.g., jumping, squatting, running, ascending or descending stairs
  • Periods of prolonged sitting
• Tenderness over medial and lateral patellar facets
• Crepitus during knee flexion ^[18]
• Buckling of the knee during weight-bearing

Diagnosis ^[16][17][18]

• Clinical diagnosis: characteristic clinical features present without signs of other tibiofemoral pathology (e.g., locking, clicking, effusions, erythema, or warmth)
• The patellar grind test is no longer recommended to evaluate for PFPS. ^[19][20]
• Full knee X-ray series is indicated if there is: ^[18]
  • Concern for an alternative diagnosis, e.g., fracture, osteoarthritis, osteochondritis
  • No improvement after 4–8 weeks of conservative management

Differential diagnosis

• Chondromalacia patellae: damage (softening, fragmentation, or erosion) of the articular cartilage of the patella due to overuse (especially during flexion) or trauma ^[16][21]
• Osteoarthritis
• Osgood-Schlatter disease
• Patellar stress fracture
• Patellar tendinopathy

Treatment ^[16][17][18]

• Acute phase ^[2]
  • POLICE principle
  • NSAIDs
  • Relative rest
• Recovery phase
  • Physical therapy
  • Hip and knee exercises (e.g., quadriceps strengthening)
  • Foot orthoses (for overpronation)
  • Temporary activity modification: switching to low-impact activities (e.g., biking, swimming)
  • Consider weight management for overweight or obese patients. ^[22]
  • Surgery (often a last resort) ^[23]
    • Indications: severe knee malalignment, symptoms persist after conservative treatment
    • Does not usually provide sustained symptom improvement

Background ^[24][25]

• Definition: Exercise-induced pain along the posteromedial border of the tibia; that is not the result of ischemia or a stress fracture; also known as shin splints ^[25]
• Epidemiology: common in runners and military recruits
• Etiology: overuse injury
• Pathophysiology: periostitis with an imbalance of bone formation and resorption in the tibial cortex, which causes increased bone degradation

Clinical features

• Exercise-induced pain along the middle and distal posteromedial tibia
  • Early stages: Pain begins with activity and resolves during continued exercise.
  • Late stages: Pain persists during exercise and may continue at rest.
• Tenderness of the surrounding muscles
• Diffuse tenderness of the distal two-thirds of the posteromedial border of the tibia

Diagnosis

• Clinical diagnosis: typical clinical features and absence of pathological findings other than minimal swelling (e.g., no neurovascular injury, warmth, or significant swelling)
• Imaging
  • Obtain only if the diagnosis is unclear. ^[24][25]
  • MRI may help differentiate MTSS from tibial stress fractures.

Differential diagnosis of exercise-induced leg pain ^[25]

• Medial tibial stress syndrome
• Tibial stress fracture ^[25]
• Exertional compartment syndrome
• Nerve or vascular entrapment

Treatment

• POLICE principle
• Immobilization and/or bracing are not recommended.
• Surgery is rarely indicated.

Overview

Tendinous injuries of the knee include patellar tendon rupture or tear and quadriceps tendon rupture or tear.

Shared features

• History of quadriceps contraction with the foot planted (more strongly associated with quadriceps tendon rupture)
• Clinical features of acute internal knee derangement, e.g., sudden pain, swelling, decreased ROM
• Impaired or absent active knee extension

Distinguishing features

Distinguishing features of knee tendon injuries
	Patellar tendon rupture		Quadriceps tendon rupture
Etiology	Direct trauma to the infrapatellar region		Direct trauma to the suprapatellar region
Clinical features	Palpable gap in tendon inferior to the patella High-riding patella on examination		Palpable gap in tendon superior to the patella Low-riding patella on examination Cracking or tearing sensation
Distinguishing X-ray findings	High-riding patella Infrapatellar soft tissue mass		Low-riding patella Forward shift of the proximal pole of the patella

Signs of acute internal knee derangement can initially mask the distinguishing physical findings of knee tendon injuries and any associated knee ligament injuries.

Initial management of knee tendon injuries ^[4]

• Begin management of acute internal knee derangement, e.g., acute pain management and immobilization.
• Imaging is typically indicated.
  • Full knee X-ray series is preferred initially.
  • Consider MRI or ultrasound if a partial tendon tear and/or other injuries are suspected.
• Initiate non-weight-bearing status.
• Consult orthopedic surgery urgently.

Etiology ^[26][27]

• Trauma to the infrapatellar region (most common)
• Contraction of the quadriceps muscle with the foot planted, e.g., during a fall (rare)
• Chronic tendon degeneration usually precedes acute rupture.

Clinical features ^[26][27]

• Acute pain
• Inability to actively extend the knee
• A palpable gap in the patellar tendon
• Other: swelling, high-riding patella ^[28]

Diagnostics ^[26][27]

• Full knee X-ray series
  • Confirmatory findings: high-riding patella
  • Other findings: avulsion fractures, infrapatellar mass, tendon calcification (in chronic tendon degeneration)
  • Not sensitive for a partial tear of the tendon ^[4]
• MRI
  • Indications: unclear diagnosis, concern for acute intraarticular damage and/or chronic tendinopathy
  • Findings: partial or complete tendon disruption, ligament or cartilage tear, hemorrhage, and/or edema
• Ultrasound: an alternative to MRI for detecting partial tear of the tendon

Treatment ^[26][27]

See “Initial management of knee tendon injuries” for acute therapy.

• Partial tears: prolonged immobilization or operative repair depending on injury characteristics ^[29]
• Complete tears: operative repair within 2–3 weeks ^[28]

Etiology ^[26][27][30]

• Falls: eccentric contraction of the quadriceps muscle when the knee is partly flexed and the foot planted (most common)
• Trauma (e.g., direct blow) to the suprapatellar region (rare)
• Most common in adults aged > 40 years with systemic disease ^[27]

Risk factors ^[26][27][30]

• Hyperparathyroidism
• Gout
• SLE
• Rheumatoid arthritis
• Diabetes
• Glucocorticoid therapy

Clinical features ^[26][27][30]

• Acute intense pain
• Inability to actively extend the knee
• A palpable gap in the quadriceps tendon
• Other: cracking or tearing sensation, swelling

Diagnostics ^[26][27][30]

• Full knee X-ray series
  • Confirmatory finding: low-riding patella , forward shift of the proximal pole of the patella
  • Other findings: suprapatellar mass (retracted tendon), suprapatellar calcification (avulsed bone)
  • Not sensitive for a partial tear of the tendon ^[4]
• MRI
  • Indications: unclear diagnosis, concern for acute intraarticular damage and/or chronic tendinopathy
  • Findings: partial or complete tendon disruption, ligament or cartilage tear, hemorrhage, and/or edema
• Ultrasound: an alternative to MRI for detecting a partial tear of the tendon

Treatment ^[26][27][30]

See “Initial management of knee tendon injuries” for acute therapy.

• Partial tears
  • Immobilization with a hinged knee brace
  • Resistance training following immobilization
• Complete tears: operative repair as soon as possible ^[27]

Muscle strain ^[31][32][33]

• Definition: injury to myofibers resulting from forceful contraction or excessive stretching ^[4][32]
• Etiology
  • Muscles are stretched beyond the elastic limit during active contraction.
  • Site of injury is usually at the musculotendinous junction.
• Classification ^[33][34]
  • Grade I: < 5% of muscle fibers are damaged.
  • Grade II: 5–99% of muscle fibers are torn (incomplete rupture).
  • Grade III: complete tear of muscle or tendon
• Clinical features ^[4][33]
  • Acute pain exacerbated by active contraction or passive stretching
  • Swelling
  • Tenderness to palpation
  • Ecchymosis or palpable hematoma
  • Loss of muscle function
  • Palpable defect in the muscle body
• Diagnostics: primarily a clinical diagnosis ^[32][33][35]
  • X-ray: indicated if there is concern for fracture or dislocation
  • MRI or ultrasound: indicated if the diagnosis or injury severity is uncertain
• Treatment ^[31][32]
  • POLICE principle
  • Immobilization for 3–5 days
  • NSAIDS for 2–3 days ^[31][32]
  • Exercise therapy after resolution of the acute inflammatory phase
  • Other
    • Hematoma aspiration ^[31]
    • Therapeutic ultrasound ^[31]
    • Surgery: indicated if > 50% of the muscle is torn and muscle function is compromised ^[36]
• Prognosis ^[37]
  • Grade II strains: healing within 2–3 weeks; return to activity in ≥ 4 weeks
  • Grade III strains: healing within 4–6 weeks; require rehabilitation for 4–6 months

Muscle contusion ^[38][39]

• Etiology: compression of muscle against bone resulting from a direct blow
• Clinical features
  • Local swelling
  • Pain and tenderness
  • Loss of muscle function
  • Palpable mass (if hematoma is present)
• Diagnostics
  • Typically a clinical diagnosis
  • Ultrasound or MRI is indicated if expanding muscle hematoma is suspected.
• Treatment
  • Control muscle bleeding: elastic bandage, immobilization of the muscle for 24 hours ^[39]
  • Ice or cryotherapy for 48–72 hours
  • NSAIDs for 48–72 hours
  • Supported weight-bearing (i.e., crutches) until pain-free normal ROM
• Complications
  • Muscle hematoma
  • Acute compartment syndrome
  • Myositis ossificans

Delayed onset muscle soreness

• Definition: painful feeling of tension in the muscles 1–2 days after increased physical activity
• Etiology
  • Climbing uphill
  • Eccentric strength training
  • Sports that involve jumping, acceleration, deceleration, and sudden changes in direction
• Pathophysiology
  • Microtears close to the Z-line of the sarcomere → stimulation of muscle hypertrophy
  • If the load or the level of physical activity is too high → inflammatory reaction near the Z-line → greater muscle repair and less muscle hypertrophy and pain due to muscle edema
  • Based on current knowledge, the build-up of lactate does not play a role in muscle soreness. ^[40][41]
• Clinical features
  • Pain on moving and/or stretching the affected muscles, muscle tenderness
  • Pain peaks after 1–3 days
  • Muscle stiffness
• Diagnostics: clinical diagnosis
• Treatment:
  • Avoid rest
  • Cycling, jogging at low intensity
  • Warmth (e.g., applied heat)
  • Careful passive stretching
• Prognosis: Spontaneous healing usually occurs within a few days.

Upper extremity neuropathies ^[42][43]

Lower extremity neuropathies ^[44]

Management ^[42][43][44]

Diagnosis is primarily clinical. Electrodiagnostic studies may be required in individuals with atypical presentation or symptoms refractory to conservative management. See “Peripheral nerve injuries” for details.

• Conservative management
  • In most cases, compression neuropathies can be treated with conservative management.
  • The optimal duration of conservative management varies from 3 to 12 months depending on the nerve involved and symptom severity. ^[43]
  • Measures include:
    • Patient education
    • Relative rest ^[42]
    • Activity modification to prevent further nerve compression
    • Symptom management (e.g., analgesia, splinting)
    • Physical therapy (e.g., range of motion exercises, exercises to strengthen compensatory muscles)
• Surgical decompression: Consider for individuals with refractory symptoms.