Sports Injury Assignment

Moira Ijzerman

Georgetown District High School

Patellar Dislocation

What is a Patellar Dislocation?

The patella rests in a groove on the anterior aspect of the femur, called the patellofemoral groove (American Academy of Orthopedic Surgeons, 2011). Patellar dislocation occurs when the patella (kneecap) slides laterally out of the patella femoral groove where it normally rests (Ebraheim, 2011).

Anatomy

The patella bone protects the largest joint in the body, the knee (Temertzoglou & Challen, 2003). The knee is made through the union of 3 bones; the femur, tibia and the patella. (Physio Advisor, n.d.). The patella is situated at the anterior aspect of the knee and lies within the patellofemoral groove (Ebraheim, 2011) which, according to Physio Advisor (n.d.) is located on anterior of the femur. The patella is enveloped by the tendon of the quadriceps muscle, and then goes on to attach to the anterior surface of the tibia (Physio Advisor, n.d.). This relationship forms a joint designed to give the quadriceps muscle leverage when extending the knee (Sports Injury Clinic, n.d.). Each of the bones involved is lined with cartilage to allow cushioning between the bones. The patella also has connective tissue known as the patella retinaculum which attaches it on either side of the femur. This joint is known as the patellofemoral joint (Physio Advisor, n.d.).

The patella normally lies in the patellofemoral grove and is only designed to move vertically within it, so dislocation occurs when the patella moves or is moved onto the outside of the patellofemoral groove and onto the lateral femoral condyle (Sports Injury Clinic, n.d.).The patella is usually dislocated laterally however vertical, superior and intercondylar dislocations may also occur (Davenport & Roch, 2013). During dislocation, tearing of the patellar retinaculum usually occurs, and joint surfaces will be damaged. There may also be an associated facture (Physio Advisor, n.d).

Mechanism of Injury

Usually patellar dislocation occurs when the force pushing the patella out of its normal position in the patellofemoral groove are too great for the quadriceps muscles and patella retinaculum to resist. This can occur through a variation of ways. Excessive twisting due to a direct blow to the inner aspect of the patella are the most common. In the absence of trauma, patellar dislocation is common in young girls who are hyper flexible (Physio Advisor, n.d.). However, there are factors that can make patella dislocation more likely, such as insufficient quadriceps strength on the medial aspect of the knee, over pronation of the feet and a larger Q angle of the knee (Sports Injury Clinic, n.d). If the vastus medialis obliqus muscle, VMO for short, is not strong enough the patella is more susceptible to dislocation because the VMO is responsible for maintaining the stability on the inside of the knee (Ebraheim, n.d.). Over pronation of the feet is when the feet roll in, turning the leg medially, causing the patella to move laterally as the quadriceps contract (Sports Injury Clinic, n.d.). According to Temertzoglou and Challen (n.d), the Q- angle is measured from a line drawn from the centre of the patella to the anterior superior iliac spine, and another line drawn from the centre of the tibial tuberosity to the center of the patella, extending up the thigh. The width of the pelvis determines how large the Q-angle is, and since women typically have wider hips then males, their Q angle tends to be larger. Any Q-angle greater than 20 degrees puts the individual at a higher risk of patellar dislocations (Wheeless, 2012).

Signs and Symptoms

Patients with this condition usually experience intense, sudden pain on the anterior of the knee during injury. This pain is usually associated with the knee ‘giving out’ and a popping sensation as the patella is now located on the lateral femoral condyle (Physio Advisor, n.d). Swelling is common and may occur rapidly in the first 1-2 hours after injury, and a lump may form on the lateral side of the knee (Ebraheim, 2011). After the patella is returned to its original position in the patellofemoral groove, a dull ache is usually experienced, and sharp pains may occur with activities that require flexion or extension of the knee, such as going up and down stairs, running, squatting and jumping. Clicking and grinding sounds may be associated with flexion and extension of the knee. Rarely, evidence of quadriceps muscle wasting is found (Physio Advisor, n.d).
Treatment

To effectively treat a patellar dislocation, apply the RICE principles to the injured knee. Ice should be applied for 10-15 minutes every hour, reducing to 2-3 times a day as symptoms gradually reduce. Rest from sports and other activity is key. A patient who has already had one case of patellar dislocation is far more susceptible to another. A knee support and patella stabilizing brace can provide stability for the joint and for the kneecap (Sports Injury Clinic, n.d.). Using knee immobilizers and braces for 2-3 weeks after injury will allow medial structures and ligaments to heal. Usually the patella will relocate itself (Ebraheim, 2011), however if it doesn’t, a physiotherapist can fix it properly as it is a safe and simple procedure. For the more uncommon types of dislocations such as horizontal, vertical and intercondylar dislocations, an orthopedist should be consulted (Davenport & Rosh, 2013). X-rays should be taken and examined carefully for a sign of a fracture, as surgery may be required if there are loose osteochondral fragments displaced in the knee joint (Ebraheim, 2011).

Interesting Information

Dolphins TE Dustin Keller is one of the unfortunate victims of patellar dislocations. Not only did he dislocate his knee, he tore his ACL, MCL and PCL when opposing player Swearinger hit him on the lateral side of his right knee, forcing the knee to move medially out of the patella femoral groove. His recovery will be long and very complex, as he must slowly and systematically work and treat each individual muscle group in rehabilitation. Injuries like this are common in contact sports like football (Siebert, 2013)

(Family Practice Notebook, n.d.)

Rotator Cuff Tear

What is a Rotator Cuff Tear?

A rotator cuff tear is an injury characterized by partial or complete tearing of one or more of the rotator cuff muscles. The rotator cuff consists of four muscles which extend to the humerus from the scapula and wrap themselves around the shoulder joint, holding it in place (Temertzoglou & Challen, 2003, p.51). As a group, the rotator cuff acts to provide stability to the shoulder joint and help with rotation and elevation of the shoulder movements (Physio Advisor, n.d). Too much stress or repetition may cause partial tears and swelling in the tendons of the rotator cuff, and any sudden stress may even cause a tendon to pull away from the bone and/or tear in the middle of the tendon (WebMD, n.d.). There are two different types of tears, a partial tear and a full thickness tear. A partial tear damages the soft tissue, but does not sever it completely. A full thickness tear is a complete tear as it splits the soft tissue into two pieces, creating a hole in the tendon (American Academy of Orthopedic Surgeons, n.d).

Anatomy
The four muscles that make up the rotator cuff are the supraspinatus, infraspinatus, subscapularis and the teres minor. The supraspinatus, infraspinatus and teres minor help stabilize the shoulder joint. Each muscle has a different job. Supraspinatus abducts the shoulder while the infraspinatus and teres minor laterally rotate the shoulder. The subscapularis rotates the humerus medially (Temertzoglou & Challen, 2003, p.51). The shoulder is a ball-and-socket joint made up of two bones, the humerus and the scapula. The humeral head rotates in the genoid fossa of the scapula, which is held in place by ligaments in the shoulder (American Academy Of Orthopedic Surgeons, n.d). The supraspinatus, infraspinatus and teres minor share a tendinous insertion on the greater tubercle of the humerus, therefore when a tendon is torn or injured, all three muscles are affected (Temertzoglou & Challen, 2003, p.75). Between the rotator cuff and the acromion, there is a lubricating sac called a bursa, which allows tendons to glide freely when the arm is moved. When the rotator cuff tendons are injured or damaged, this bursa can also become inflamed and very painful (American Academy Of Orthopedic Surgeons, n.d).

Mechanism of Injury

There are several factors that contribute to the rotator cuff tear injury. A rotator cuff tear may develop over time due to activities placing strain on the rotator cuff for prolonged periods of time (Physio Advisor, n.d). Repeating the same shoulder motions over and over can cause stress to muscles and tendons, gradually weakening the rotator cuff. Swimming, tennis and baseball are examples of sports that can put athletes at a higher risk for overuse tears (American Academy of Orthopedic Surgeons, 2011), however everyday activities such as painting and carpentry can cause a tear if overhead motions are done repeatedly (Mayo Clinic, 2014). As we age, the blood supply in our tendons lessens dramatically. A lack of blood supply can inhibit the body’s natural ability to repair tendon damage, ultimately leading to a tear. As people age, bone spurs also begin to form. When someone with a bone spur abducts their arm, the spur rubs on the rotator cuff tendon and overtime will weaken the tendon and make it more likely to tear. Since most rotator cuff injuries are caused by wear and tear, people over 40 are at a higher risk, along with athletes (American Academy of Orthopedic Surgeons, 2011).

Signs and Symptoms

There are multiple symptoms of a rotator cuff injury. The most common include pain at night or while resting, especially if lying on the injured shoulder, pain when abduction, adduction and rotating the arm, or other specific movements, increased weakness when adducting your arm while bearing some weight and clunking or popping sensation when moving the shoulder in certain positions. At first, the pain may be mild, however overtime it will become more noticeable. Tears from a sudden accident, such as a fall, cause immediate intense pain and weakness in the arm, accompanied with a snapping sensation (American Academy of Orthopedic Surgeons, 2011). In very severe cases, muscle wasting may be present. Occasionally an Ultrasound or an MRI scan may be needed to confirm the diagnosis and severity of the tear (Physio Advisor, n.d).

Treatment It is best to get treatment right away for any type of rotator cuff tear, as they become more severe as time passes (Sports Injury Clinic, n.d.). Nonsurgical treatment is effective in around 50 percent of patients; however shoulder strength doesn’t usually improve without surgery if the tear is severe (American Academy of Orthopedic Surgeons, 2011). Applying ice and resting the injured shoulder is essential for a torn rotator cuff or tendon as it is an effective way to reduce pain and inflammation. Apply for 10 minutes every hour, reducing to just 3 or 4 times a day as the pain gradually reduces (Sports Injury Clinic, n.d.). Avoid any activities with arm movement and if possible wear sling to help protect the shoulder and immobilize it. Non-steroidal anti-inflammatory medication such as Ibuprofen will help reduce pain and swelling (American Academy of Orthopedic Surgeons, 2011). A registered massage therapist can help by giving the injured muscles a massage, which includes cross friction to the rotator cuff tendon and can break the injury down into an acute stage to allow correct healing to occur. Some patients get referred for a steroid injection directly into the site of the injury to reduce inflammation. Once the injury is manageable, patients are given a full rehabilitation program consisting of stretching and strengthening exercises. However, surgery may be needed to repair the tear. If after 6-12 weeks nonsurgical treatments have not had the desired effects, the patient is under 60 years old and/or the patient’s job requires constant shoulder movement then surgery may be an effective option (Physio Advisor, n.d). Surgery to repair a torn rotator cuff usually involves the re-attachment of the tendon to the greater tubercle groove on the humerus (American Academy of Orthopedic Surgeons, 2011).

Interesting Information

A rotator cuff tear is so common in any aquatic sport it is nicknamed Swimmers Shoulder. Even though swimming is considered a low impact sport, the continuous rotation of the shoulder can cause stress tears and lead to more serious injuries. An a single practice, a swimmer can rotate their around 2500 times, with more competitive athletes almost doubling that. (Enjoy Swimming, n.d.)

(Jaffe Sport Medicine, n.d.)

Inversion Ankle Sprain

What is an inversion ankle sprain?

An inversion ankle sprain refers to the tearing of ligaments found on the lateral side of the ankle, and is one of the most common athletic injury (Kinetic Health, n.d).

Anatomy

Inversion sprains are so common because the lateral malleolus distal fibula extends further down than the medial malleolus, and this difference gives the medial side of the ankle more stability than the lateral side (Kinetic Health, n.d). There are multiple ligaments found in the ankle, and in the case of an inversion sprain, there a several affected ligaments (American Orthopaedic Foot & Ankle Society, n.d). The stability achieved on the lateral side of the ankle is from a three-ligament complex. The ligaments are called the Anterior Talofibular ligament, Calcaneofibular ligament and the Posterior Talofibular ligament. The anterior talofibular ligament is the most commonly injured in an inversion sprain. This ligament connects to the fibula and the talus bone and prevents anterior displacement of the talus/ankle. In a severe inversion sprain the calcaneofibular ligament may be damaged alongside the anterior talofibular ligament. The calcaneofibular ligament connects the calcaneous bone with the fibula, and is not damaged easily as it is stronger than the anterior talofibular ligament. The posterior talofibular ligament is rarely injured. The sprain has to be very severe as the posterior talofibular ligament is only damaged when there is a complete dislocation of the talus. This ligament is the strongest out of the three ligaments in the complex. However, an inversion ankle sprain may also damage other structures such as connective tissue, muscles further up the ankle and tendons (Kinetic health, n.d.). Avulsion fractures, where a miniscule piece of bone is pulled away by a tendon or ligament is also possible, as well as osteochondral lesions, which are small tears of the cartilage that lines the anterior of the talus bone (Sports Injury Clinic, n.d).

Mechanism of Injury

An inversion ankle sprain most commonly occurs during activities which involve jumping and landing, rapid changes in direction and unnatural twisting on the ankle (Physio Advisor, n.d.). When you jump, the ankle plantar flexes with a large force, but cannot return to its neutral position when the body comes down, making the ankle more inverted than its normal range of movement which results in an inversion sprain (Temertzoglou & Challen, 2003, p.79.). An athlete may sprain their ankle from another athlete landing on their foot, resulting in the ankle being turned inwards excessively. People may be more susceptible to a sprain due to small factors much as inappropriate footwear, poor foot posture or biomechanics, inappropriate training and a inadequate warm up. After having one sprain, patients are more susceptible to having another injury (Physio Advisor, n.d).

Signs and Symptoms

Ankle sprains can be graded on a scale from one to three, depending on the symptoms present. In a grade one sprain the patient can still walk, yet there may be some difficulty. There may be swelling, stiffness and pain, as there is only minor tearing of the ligaments. The ankle joint still remains somewhat stable. In a grade two sprain the patient could be in severe pain while walking, and there may be bruising and swelling and the ankle will be somewhat unstable. In a grade three sprain one or more ligament(s) is completely torn. The ankle is completely unstable, and the patient cannot walk or bear weight on the ankle (Kinetic Health, n.d.). Severe pain will be felt initially with extensive bruising (Sports Injury Clinic, n.d.).

Treatment

Surgery in not required in the majority of ankle sprains, however it depends of the grade of the sprain. Patients who can bear any weight on the ankle after injury are likely to return to sports and activities more rapidly (American Orthopaedic Foot & Ankle Society, n.d.). After spraining the ankle, it is crucial that the patient tries to reduce swelling immediately. The quicker the injury is addressed, the quicker it will heal. Use RICE, rest, ice, compress and elevate. Post-injury, it may be necessary to take all weight off the injured ankle. Crutches may be used, or a wheelchair (Kinetic health, n.d). Ice should be applied for 10 to 15 minutes every hour for the first two days. A compression bandage can be applied immediately after the injury, but should remain on the ankle for only 10 minutes at a time to present blood starvation at the site of the injury, which could result in further injury. Swelling can also be reduced by ankle wraps and taping techniques (Sports Injury Clinic, n.d). The injured ankle should be positioned so that the toes are at the same level as the patients’ nose. When pain gradually decreases, a full rehabilitation program should be undertaken. Surgery is not commonly required, however if there is cartilage damage or the patient has chronic instability, surgery may be the best option (American Orthopaedic Foot & Ankle Society, n.d.).

When the ligaments are healing after an inversion sprain, scar tissue formation may be an issue. When ligaments are torn, the body lays down collagen to support, reconnect and reinforce damaged tissue, however this tissue is considerably weaker, more inflexible and easier to tear than normal ligaments as it is laid down is a random patter and doesn’t follow to same fiber orientation as the normal ligaments. This furthers instability and can result in further injuries. It may be necessary to remove this tissue (Kinetic Health, n.d). A full recovery period can range from several days for acute sprains, to several weeks for severe sprains (American Orthopaedic Foot & Ankle Society, n.d.).

Interesting Facts Female athletes are more susceptible to ankle strains than males are in a grade one sprain. However, the difference is not significant between the sexes in more serious sprains such as grade two and three. For both sexes the risk of an ankle sprain doubles as the level of competition increases from high school to varsity. These findings are opposite to anterior ligament tears (Beynnon, Murphy & Alosa, 2002).

(American Orthopaedic Foot & Ankle Society, n.d.)

References

American Academy of Orthopedic Surgeons. (2011). Patellofemoral Arthritis. Retrieved from http://orthoinfo.aaos.org?topic.cfm?topic=A00S90 American Academy of Orthopedic Surgeons. (2011) Rotator Cuff Tears. http://orthoinfo.aaos.org/topic.cfm?topic=a00064#topic.cfm?s=2&_suid=1413748217022024695442512022736 American Orthopaedic Foot & Ankle Society. (n.d.) Ankle Sprain. Retrieved from http://www.aofas.org/footcaremd/conditions/ailments-of-the-ankle/Pages/Ankle Sprain-.aspx
Beynnon B. B., Darlene. M. F., Denise M. A. (2002). Predictive factors for Lateral Ankle Sprains:
A Literature Review. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC164368/ Davenport, M., Rosh, A. J., (2013) Patella Dislocation Joint Reduction. Retrieved from http://emedicine.medscape.com/article/109263-overview#a17

Ebraheim, N. (2011). Patellar Dislocations – Everything You Need To Know – Dr. Nabil Ebraheim. YouTube. Retrieved from http://youtu.be/TVTmz0zAsqA
Enjoy Swimming. (n.d.) Swimmer’s Shoulder Causes and Preventions. http://www.enjoy swimming.com/swimmers-shoulder.html
Family Practice Notebook. (n.d.) Rotator Cuff Injury. Retrieved from http://www.fpnotebook.com/legacy/Ortho/Shoulder/RtrCfInjry.htm
Jaffe Sports Medicine. (n.d.) Should you Exercise with a Rotator Cuff Tear? Retrieved from http://jaffesportsmedicine.com/exercise-rotator-cuff-tear/ Kinetic Health. (n.d.). Ankle Sprains or Inversion Sprains. Retrieved from http://kinetichealth.ca/ankle-sprains-or-inversion-sprains/ Mayo Clinic Staff. (2014). Rotator cuff injury. Retrieved from http://www.mayoclinic.org/diseases-conditions/rotator-cuff injury/basics/definition/CON-20031421 Physio Advisor. (n.d) Patellar Dislocation. Retrieved from http://www.physioadvisor.com.au/10276750/patellar-dislocation dislocated-knee-cap-physi.htm
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Physio Advisor. (n.d.) Sprained Ankle (Lateral Ligament Sprain) Retrieved from http://www.physioadvisor.com.au/8036750/sprained-ankle-rolled-ankle-ankle-sprain phy.htm
Siebert, D. (2013) Dustin Keller’s Knee Injury: Examining His Knee Dislocation and What Lies
Ahead. Retrieved from http://bleacherreport.com/articles/1745135-dustin-kellers-knee injury-examining-his-knee-dislocation-and-what-lies-ahead Sports Injury Clinic. (n.d) Ankle Sprains. Retrieved from http://www.sportsinjuryclinic.net/sport injuries/ankle-achilles-shin-pain/sprained-ankle Sports Injury Clinic. (n.d) Patella Dislocation. Retrieved from http://www.sportsinjuryclinic.net/sport-injuries/knee-pain/patellar-dislocation Sports Injury Clinic. (n.d) Rotator Cuff Tear. Retrieved from http://www.sportsinjuryclinic.net/sport-injuries/shoulder-pain/rotator-cuff-strain Temertzoglou, T. & Challen, P. (2003) Exercise Science: An Introduction to Health and Physical
Education. Ontario: Thompson Educational Publishing, Inc. Wheeless. C. R. (2012) Q angle of the Knee. Retrieved from http://www.wheelessonline.com/ortho/q_angle_of_the_knee WebMD. (n.d) Rotator Cuff Tear. Retrieved from http://www.webmd.com/fitness
exercise/guide/rotator-cuff-tear