Sport medicine

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Groin pain is a common complaint among athletes (up to 6% in some reports).  Groin pain can be acute or develop insidiously or chronically.  The term ‘groin pain’ refers to anterior pain.  Posterior, buttock pain, in athletes is a different issue.

Causes of groin pain in athletes

Many times it is not fully understood why an athlete suffers from groin pain, as objective findings are scarce.  In other cases, findings are abundant and the diagnosis is straightforward.  Anyway, groin pain is more common is sports in which there is repeat kicking, direct contact and running with frequent change in direction.

Typical names for groin pain in athletes include the following:

• Pubalgia
• Sport hernia – a condition that resembles a true hernia in its presentation but without a true deficit in the abdominal wall.  Pain is aggravated by coughing, valsalva etc.
• Gilmore’s groin
• Conjoint tendon injury
• Adductor muscle injury
• Urologic conditions
• Pelvic bone disease – with or without primary structural deficit

Treatment of groin pain in athletes

Most cases of groin pain in athletes will resolve on their own.  Sometimes surgical treatment will be offered, especially if hernia is suspected.  In this case it is common to find separation of the external oblique fibers.  After surgery the athlete returns to activity gradually within 10 weeks on average.  Reported success rate exceeds 85%.

Anterior knee pain is a very common complaint among people who participate in sports and in the general public.  Over the years many theories have been developed to try and understand the cause of anterior knee pain.  It has been blamed on lower limb mal-alignment (“patello-femoral syndrome” – the most common diagnosis given to this condition in people engaged in sports activity and also known as “anterior knee pain” and “runners knee”), on muscular weakness, on hyperlaxity, over training, cartilage failure (“chondromalacia patella”) and more.  A sub-type of knee pain, knee instability, has been discussed elsewhere.  Also, this article will not discuss the various non-idiopathic reasons for anterior knee pain (such as obvious anatomical variations, fracture, trauma, tumor, inflammation of various structures within the knee joint and around it, Osgood-Schlatter disease or Sinding-Larsen-Johansson syndrome).

The various anatomical structures and mal-alignments blamed for anterior knee pain range from the hip to the feet.  Unequal leg length, external rotation of the femur, increased Q angle, pes planus, high riding patella (‘patella alta’) or low riding patella (‘patella baja’) – these are just examples.  Another cause often blamed as a cause for anterior knee pain is weakness of the cartilage behind the patella – “chondromalacia patella”.  This is probably only true in a minority of cases.  These are all static causes of knee pain and the evidence supporting them is rather poor.  It is now believed that most anterior knee pain is due to defects in dynamic factors.

Symptoms of anterior knee pain

Anterior knee pain, as its name implies, is a cause of pain in the patellar area.  However many patients describe pain around or even behind the patella.  Pain is aggravated by activity and especially walking up or down stairs (or a hill), squatting and running.  Another type of complaint is stiffness or discomfort in the knee / knees after sitting for a prolonged time with knees flexed.

That being said, unilateral knee pain should sometimes be investigated further.  The term ‘anterior knee pain’ and the aforementioned obscurity that surrounds it usually relate to bilateral pain.  Unilateral pain may have another cause (even if it is gluteus medius weakness, as stated).

A symptom to look out for is the knee giving way.  Giving way of the knee can be part of anterior knee pain, however it can also insinuate that there is knee instability or patellar dislocation.

Examination of a patient with anterior knee pain

The knees should be inspected and palpated.  Both legs should be compared and obvious malalignment or structural abnormalities should be noted.  There are several maneuvers that help make the diagnosis:

• Single leg squat – This maneuver can disclose patellar instability or a weak gluteus medius.  If the gluteus medius is weak the knee on the affected side will bend inward and a normal knee will stay straight.  A weak vastus medialis oblique will be evident because the patella will move outward and up.
• Patellar glide – this test assesses the mobility of the patella.  Anterior knee pain can be a result of a patella that is too tight or too mobile.
• Patellar tilt – The patalla is grasped while the leg is extended and the lateral side is lifted.  This should be possible at least to 0 degrees.  If the patella can not be tilted this means the lateral structures are too tight.
• Patellar grind (patallar inhibition test) – The patella is compressed while the leg is extended (the patient is lying down).  The patient contracts the quadriceps.  If pain is elicited, this is a positive patellar inhibition test.

Proven risk factors for anterior knee pain

Risk factors for anterior knee pain can be divided into local risk factors around the knee and systemic / general risk factors that involve the whole body.  The following are proven general risk factors for anterior knee pain:

• Obesity
• Lack (!) of physical activity or improper training
• Young age (especially if over active)
• Depression

Local risk factors for anterior knee pain are related to abnormal knee tracking.  This means that the patella does not move in the exact proper plane it should, thus being exposed to higher than normal forces and thus suffering pain.  Examples include patellar malalignment, muscle dysfunction or uncoordination, muscle weakness, patellar hypermobility or too tight lateral structures etc.  Some of these risk factors are inborn, while others are acquired after surgery, trauma or wrong training habits.

Treatment of anterior knee pain

The treatment of anterior knee pain is usually conservative.  Surgery is rarely if ever indicated.  Treatment consists of relative rest, but not complete rest.  Specific exercises are deployed to strengthen the quadriceps and specifically the vastus medialis.  Gluteus medius strengthening is also warranted.  The idea behind these exercises is correcting the patellar improper tracking.

If osteoarthritis is suspected to play a role in a particular patient’s complaints, then osteoarthritis treatment can be tried.  Other forms of treatment such as better fitting sneakers, braces and taping can be tried with varying success rates.

Surgical options for anterior knee pain treatment include lateral release (if it is assessed that the lateral forces on the patella are too tight), proximal realignment and distal realignment.

Further reading

1. Management of patellofemoral syndrome.  American Family Physician. 2007; 75: 194-202.

Osteoarthritis is a chronic condition involving eroding cartilage and secondary exposure of bone.  Osteoarthritis affects millions of people around the world.  Common joints that are involved in osteoarthritis include the knees and ankles (weight baring joints).  Osteoarthritis is a cause of functional limitation and chronic pain.

Risk factors for osteoarthritis

There are several proven risk factors for osteoarthritis.  These include obesity, genetic pre-disposition, injury to a joint and joint mal-alignment and certain chronic inflammatory joint diseases.  Several occupations are considered risk factors for particular joint osteoarthritis.  Examples include osteoarthritis in the wrists in drillers and hip osteoarthritis in professional football players.  For more examples read this review.  However, in most cases physical activity is not a risk factor for osteoarthritis, as long as there is no previous joint injury and / or previous joint malformation.  Of note, there is inconclusive data regarding repetitive high impact sports.  Also, there is much data regarding the protective effects of physical activity on osteoarthritis (see bellow).

Treatment of osteoarthritis

Osteoarthritis can be treated medically or surgically.  Before going into the various treatment options for osteoarthritis it is important to note:  there is no “quick fix” to osteoarthritis.  In fact the science of medicine does not have a good treatment for osteoarthritis whatsoever.  All treatments used today to treat osteoarthritis are meant to slow the process and relieve symptoms.

Medical treatment of osteoarthritis

The medical treatment of osteoarthritis is divided into core treatments and complimentary treatments.

Core treatment for osteoarthritis:

• Patient education
• Psychological, sociological and functional support
• Weight loss – People who are overweight have an elevated chance of developing osteoarthritis that is 2-3 times higher than non-obese persons.  Being overweight actually poses a dual barrier in treating osteoarthritis – overweight people not only have more osteoarthritis, but also find it more difficult to be physically active.  Physical activity, on the other hand, is important for both the treatment over obesity and osteoarthritis.  Weight loss is a treatment for osteoarthritis on its own (and other conditions).
• Physical activity – Physical activity has been shown to reduce the symptoms of osteoarthritis in the long run.  Regular low impact physical activity and strengthening the muscles around the affected joints reduce pain.  It has been shown that it does not matter how the patient is convinced to perform activity, as long as they participate.

Complimentary treatment for osteoarthritis – medication:

Medication is used to complement the above mentioned core treatment for osteoarthritis and patients should understand that.  Poor patient education can lead to frustration and over utilization of pain medication up to harmful side effects.

• Dypirone and acetaminophene
• Algolysin forte – A combination of propoxyphene (a weak opioid) and acetaminophene.  It is quite efficient in managing pain but there is a standing FDA warning due to increased mortality reports.
• NSAIDs - Non steroidal anti-inflammatory drugs – Very common, some over the counter drugs.  Examples include naproxene and iboprufen.  Side effects include (among others) increased blood pressure, congestive heart failure exacerbation, gastrointestinal bleeding and impaired renal function.  Some have been linked to increased cardiovascular mortality.  On the other hand they are efficient pain medication.  It is recommended to used NSAIDs sparsely for osteoarthritis and avoid chronic use.
• Dietary supplements – Dietary supplaments and particularly cartilage enhancing or cartilage component supplements have become very popular over recent years.  The three available cartilage containing supplements are glucosamine sulfate, glucosamine hydrochloride and chondroitin sulfate.  A recent review published in the American Family Physician did not recommend against trying these supplements for a 60 day period before deciding whether they worked for a particular patient or not.  The NIH funded GAIT study showed potential benefit in specific groups of patients with knee osteoarthritis.  Side effects of glucosamine and chondroitin compunds are reported to be minor (mainly gastric discomfort).  Another issue to pay attention to is prescribing the proper dose – reported success is achieved with high doses, that often are not present in poorly supervised dietary supplements.
• Diacerein - ART 50 (trade name Artrodar) – Works by countering inflammation through IL-1.  There is some data to support a trial with diacerein, and a Cochrane review from 2006 supported that.  However, of note, some people do not benefit.  Also, most evidence is derived from the hip joint.  Side effects include loose stools.  There is no FDA approval for diacerein use to date.
• Opioid pain medication – these medications should not be used routinely in osteoarthritis patients, but only for very severe exacerbations and peri-operatively.
• Injections – Treatment of osteoarthritis with injections includes several types of injections.  Injections can be around the joint (anesthesia, for example) or intra-articular.  Injections into joints consists of anesthesia, hyaluronic acid or steroids.  Data regarding hyaluronic acid in large joints showed that repeat injections into large joints improved pain, but it is not clear whether it is better than other medication.  Intra-articular steroids could have various local and  systemic effects, but are considered effective in acute exacerbations.
• Topical treatment for osteoarthritis – Several ointments are used to treat osteoarthritis including caspaicin for pain and diclofenac for inflammation.  There is a recent FDA warning regarding diclofenac gel and hepatic function.
• Complementary medicine – complementary medicine such as acupuncture and hot water springs have been tried with variable results.  It probably does no harm in the case of osteoarthritis.

Ankle sprains are some of the most common injuries in sports.  Other names for ankle sprain include twisted ankle and rolled ankle.  A sprained ankle can have a limiting effect on a professional athlete’s season and on any athlete’s performance in the long term.  Long term consequences of sprained ankles such as ankle instability and failed proprioception make this an important injury to know how to diagnose and treat.

An ankle sprain happens when the ankle rolls more than it can and ligaments are torn.  The most common for of ankle sprain is when the lateral ankle ligaments (lateral ankle complex) are torn.  This type of ankle sprain occurs when the foot rolls inward in inversion, thus tearing the outer ligaments.  This means that the ligaments tying the fibula, talus and calcaneus are torn.  A torn deltoid ligament (medially) or syndesmosis (known as a ‘high ankle sprain‘ – a sprain at the level between the tibia and the fibula) are also possible, but less common.

Classification of ankle sprains

Ankle sprains are classified according to their location and severity.  Location of ankle sprains, as mentioned above, can be lateral (85%), high (10%) or medial (5%).

In most all ankle sprains the first ligament to be injured is the anterior talo-fibular ligament.  Severity classification of ankle sprains depends on how badly the ligament has been injured and which ligaments are injured next, is as follows:

• Grade I – Partial tear of the lateral ligaemnts.  The anterior-talofibular ligament is the main ligament affected.  There is minimal instability on examination and anterior drawer is normal.
• Grade II – Decreased motion and stability.  The anterior talo-fibular ligament is torn while the calcaneo-fibular ligament is intact but damaged.  There is laxity on inversion and an anterior drawer is present.
• Grade III – The whole lateral ligamentous complex is torn (the posterior talo-fibular ligament is the last to be afflicted).  This results in total loss of function, diffuse swelling, marked instability.

Because all sprains will result in swelling of the ankle, examination and primary classification of ankle sprains should be done within 72 hours.

Clinical presentation of ankle sprains

Ankle sprains are painful.  The pain can be followed by swelling.  The pain in ankle sprain starts of as point tenderness over the affected ligaments and structures, but quickly becomes diffuse as hemorrhage and edema move in.

Ankle sprains result in two types of ankle instability - Mechanical and functional:

• Mechanical instability can be demonstrated by taking dynamic x-rays under strain (with a machine that bends the ankle at preset angles and forces – stress views).  Mechanical instability is diagnosed when there are more than 6 degrees lateral tilt or 2 mm posterior opening.  Mechanical instability usually refers to instability of the subtalar joint.  Mechanical instability is present when the ligaments of the subtalar joint are damaged – first the anterior talo-fibular, then the calcaneo-fibular, but also the cervical and inter-osseous  ligament (bifurcate ligament) of the sinus tarsi.
• Functional instability is more difficult to measure because it is a consequence of loss of proprioception and results in functional difficulty to walk over uneven surfaces.  It is the functional instability that cases recurrent ankle sprains, due to carelessness of the patients who are unaware of their problem.  Functional instability is diagnosed when there is a subjective feeling of the ankle giving way or 3 or more ankle sprains withing a year.

Ankle locking is not a part of the normal symptoms of ankle sprain.  If there is ankle locking a fracture in the talar dome should be suspected.

Treatment of ankle sprains

Ankle sprain treatment can be divided into conservative and surgical.  In most cases surgical treatment for ankle sprains will not be oped for.  In grade I and grade II ankle sprains functional treatment results in great long term results.  There is controversy regarding grade III ankle sprains, however surgery is not automatic.  Long non-weight baring and slow rehabilitation is also an option for grade III ankle sprains.

The goal of conservative treatment for ankle sprain is functional rehabilitation.  Rehabilitation should be done with particular attention given to stability.  Some exercises might be done with an ankle brace or aircast.

Conservative treatment for ankle sprains can be conceptually divided into three phases, as time elapses from the injury.  During the acute phase after ankle sprain the PRICE method is used:  Protection, Rest, Ice, Compression and Elevation.

In the second phase, weight bearing is begun gradually.  Leg balance exercises are employed.  For example, one legged hopping or standing on an uneven surface such as a surface with a ball base.

After 3-6 weeks, agility and functional drills (walking, running and jumping) are encouraged aiming for sports specific drills.  The time frames mentioned here are only estimates, as a particular patient’s characteristics dictate the rate in which treatment will be done.

Indications for surgical treatment are high grade ankle sprain with instability.  Regarding high ankle sprains (syndesmosis injury) specific indication for surgery include widening of the syndesmotic interval to 2 mm or more and lateral shift of the talus.  Some say that medial ankle injuries such as those from pronation – external rotation are indications for surgery.  In all of these cases the reduction has to be very accurate.  Surgery can be augmentation or capsular stretching and reefing