The treatment of sports-related injuries requires a multidisciplinary approach in order to provide the best care to athletes with specific needs. Sports medicine consists of injury prevention, diagnosis, treatment, rehabilitation, nutrition, psychology and treatment of general medical conditions. We provide a range of minimally invasive interventions, which along with a multidisciplinary approach, improves the overall treatment outcome.
Most athletic injuries can be treated conservatively, successfully and efficiently. Certain types of injuries such as fractures or severe trauma are often treated surgically. There are different minimally invasive interventions available to the injured athlete that can be used successfully and in most cases, avoid the need for further surgery. In recent years, the use of musculoskeletal sonography (sonogram) has allowed clinicians to evaluate injuries in a more dynamic and precise manner. This new technique has resulted in newer and more efficient therapeutic interventions.
The treatment of injured muscle, ligament and tendons can be optimized and in most cases the recovery can be expedited with regenerative cellular therapies such as platelet rich plasma grating and antilogous stem cell grafting. The following are some conditions that can be successfully treated with regenerative cellular therapies:
Partial Muscle Tears: Hamstrings, Abductors, Quads and Rectus Abdominus
Partial Ligament Tears: Lateral and Medial Collateral (Knee), Shoulder AC Joint, Thumb, Ankle
Partial Tendon Tears and Tendinopathy: Rotator Cuff, Achilles, ACL, Patellar, Gluteus, Tennis Elbow, Golfers Elbow
Joint, Arthritis and Overuse: Hip, Knee, Ankle, Sacroiliac, Wrist, Elbow
These are some examples that offer excellent therapeutic efficacy, potential for faster recovery and lower re-injury rates. All these interventions are always provided along with a multidisciplinary approach.
Sports Injuries: Overview
The stability of a joint is increased by the presence of a joint capsule of connective tissue thickened at points of stress to form ligaments. The ends of the ligaments attach to the bone. Ligament injuries range from mild injuries
involving the tearing of only a few fibers to complete tears of the ligament, which may lead to instability of the joint.
Complete or partial tendon ruptures may occur acutely. Normal tendons consist of tight parallel bundles of collagen fibers. Injuries to tendons generally occur at the point of least blood supple, for example, with the Achilles tendon usually 2 cm (0.75 in) above the insertion of the tendon, or at the musculotendinous junction.
A tendon rupture occurs without warning, usually in an older athlete without a history of injury in that particular tendon. The two most commonly ruptured tendons are the Achilles tendon and the supraspinatus tendon of the shoulder. The main objective of the treatment of tendon injuries is to restore full motion and function. Partial tears are characterized by the sudden onset of pain and by localized tenderness but they may be difficult to distinguish from tendinopathy.
Ultrasound ad MRI are useful techniques used for investigation. Both modalities can distinguish between a partial or complete tendon rupture and overuse tendinopathy. Generally, acute tendon rupture requires surgical treatment followed by progressive rehabilitation.
Rotator Cuff Injuries
Rotator cuff tendinopathy is a common cause of shoulder pain and impingement in athletes. In this condition, the rotator cuff tendons become swollen and hyperceullular, the collagen matrix is disorganized and the tendon weaker. Studies in running rats and in human swimmers suggest the major determinant of the onset of tendinopathy is the volume ( e.g. distance swum, time running) of work. Apoptosis (programmed cell death) and associated pathways are increased in overuse tendinopathy and may play a role in the pathogenesis of tendinopathy.
The PCL is the primary restraint to posterior drawer, and secondary restraint to external and rotation. Isolated sectioning of the PCL results in an increased posterior translation of knee under a posterior tibial load. The increase in laxity is relatively small at full extension and most pronounced at 90* flexion. Only small rotator or valgus/varus laxity results from isolated PCL injury.
Up to 60% if PCL injuries involve disruption of the posterolateral structures. The primary stabilizers are the lateral collateral ligament (LCL) and the popliteus comples. They provide varus and external rotary stability to the knee respectively. When both the PCL and posterolateral structures are cut, posterior laxity is significantly increased.
Tears of the PCL do not appear to be as common as of the ACL, due partly to the greater strength of the PCL. However, the condition is under-diagnosed. PCL injuries are often associated with meniscal and chondral injury. The incidence of associated meniscal tears varies from 16% to 28%. Longitudinal tears of the anterior horn of the lateral meniscus are the most common location. There is also a high incidence of radial tears in the middle or posterior lateral meniscus.
The incidence of significant chondral damage with isolated PCL injury was not thought to be as high as with ACL injury, but a recent study showed chondral damage in 52% of those with PCL tears, with lesions of grade III or more found in 16%.
LCL tears are much less common than MCL tears. They are usually due to a severe, high-energy, direct varus stress on the knee and are graded in a similar fashion to MCL sprains. Differential diagnosis may be an avulsion of the biceps femoris tendon.
Complete tears of the LCL are usually associated with other instabilities, such as PCL rupture, and may result in posterolateral rotator instability of the knee. These tears are best treated by acute surgical repair in conjunction with repair of other damaged ligaments. Chronic reconstruction of the LCL is difficult and results are poor. A varus knee with lateral and/or posterolateral instability appears to be associated with worse results.
Since the introduction of arthroscopy and MRI, considerable insight has been gained into the role of articular cartilage (chondral) damgage as a cause of symptoms and signals in the knee joint. Articular cartilage damage may occur as an isolated condition in which chondral or subchondral damage is the primary pathology, or in association with other injuries, such as ligamentous instability resulting from MCL, ACL or PCL injuries. ACL tears are associated with a high incidence of damage to the medical femoral condyle, lateral femoral condyle and lateral tibial plateau. Articular cartilage damage may also be seen in association with meniscal injury and patellar dislocation. Chondral injury is graded according to the Outerbridge classification and more recently the International Cartilage Repair Society (ICRS) grading system.
Articular cartilage damage in the knee has both short-term and long-term effects. In the short term, it causes recurrent pain and swelling. In the longer term, it accelerates the development of osteoarthritis. Various methods have been used to encourage healing of articular cartilage defects.
An effective method of promoting scar tissue formation in damaged articular cartilage is by continuous passive motion. Continuous passive motion has been shown to stimulate formation of hyaline-like fibrocartilage in the chodral defect, especially in the immediate post=-operative period. This should be supplemented by low load, non-weight bearing such as exercise such as swimming and cycling.
Acute patellar Trauma
Acute trauma to the patella (e.g. from a hockey stick or from a fall onto the kneecap) can cause a range of injuries from fracture of the patella to osteochondral damage of the patellofemoral joints with persisting patellofemoral joint pain. In some athletes, the pain settles without any long-term sequelae. If there is a suspicion of fracture, the patient can be assumed to be suffering acute patellofemoral inflammation.
Patellofemoral pain is the preffered term used to describe pain around the patella. Synonyms include PFJ syndrome, anterior knee pain and chondromalacia patellae. Patellofemoral pain is an ‘umbrella’ term used to embrace all peripatellar or retropatellar pain in the absence of other pathologies.
Lateral Ligament Injuries
Lateral ligament injuries occur in activities requiring rapid changes in direction, especially if these take place on uneven surfaces. They are also seen when a player, having jumped, lands on another competitor’s feet. They are one of the most common injuries seen in basketball, volleyball, netball and most football codes.
The usual mechanism of a lateral ligament injury is inversion and plantarflexion, and this injury usually damages the ATFL (anterior talofibulart ligament) before the CFL (calceneofibular ligament). This occurs because the ATFL is taut and plantarflexion and the CFL is relatively loose. Also, the ATFL can only tolerate half the strain of the CFL before tearing. Complete tear of the ATFL, CFL and PTFL results in a dislocation of the ankle joint and is frequently associated with a fracture. Such an injury is rather infrequent, however. Isolated ligament ruptures of the CFL and especially the PTFL are rare.
Ankle sprain may be accompanied by an audible snap, crack or tear, which, although often a great concern to the athlete and onlookers, has no particular diagnostic significance. Depending on the severity of the injury, the athlete may continue to play or may rest immediately. Swelling usually appears rapidly, although occasionally it may be delayed some hours.
Most cases of ankle ligament sprain resolve satisfactorily with treatment- pain and swelling settle and function improves. However, as ankle sprain is such a common condition, there remains a substantial number of patient who do not progress well and complain of pain, recurrent instability, swelling and impaired function three to six weeks after injury.