Philly.com Sports Doc
Posted: Friday September 19, 2014
Most of us by now have at least heard about, if not seen, RG III’s ankle injury against the Jaguars on Sunday, September 14. The sports media reports that he suffered an ankle dislocation without fracture. This type of ankle injury is very rare as ankle dislocations almost always happen in conjunction with a fracture of the lateral malleolus, medial malleolus and/or the distal posterior aspect of the tibia.
From watching the video of the injury, RG III’s ankle looks to roll inward. It is unclear which direction his ankle dislocated and whether it was an open or closed dislocation but one would assume that there is significant damage to his ankle ligaments, specifically his deltoid ligament.
Treatment for this injury will involve a period of non-weight bearing with cast immobilization. Once the cast is removed, his ankle will be re-assessed for any ligament laxity that may not have healed with immobilization and may require subsequent surgery. If surgery is required, the loose ligaments will either be repaired (sewn together) or reconstructed (other tissue used to replace the injured ligament).
Return to sports after ankle ligament surgery usually takes 3-6 months. If surgery is not required, he will start progressive weight bearing and rehabilitation to regain ankle range of motion/flexibility, ankle and general lower extremity strength, and lower leg balance and motor control. From there, he will initiate sports-specific activities including running. This rehab program is relatively the same whether he undergoes surgery or not. There is less published research on return to sports following ankle dislocation without fracture, but one case study showed a time frame of 6 months in a recreational athlete.
The latest news coming from the team is that he will be casted for about 10 days, will not require surgery, and that he will be back in 4-6 weeks. That time frame is extremely optimistic if it was truly an ankle dislocation. There should be a much clearer prognosis once he is out of the cast and re-evaluated. But until then, make sure you don’t have him in your starting fantasy line up.
(AP Photo/The Oregonian, Ross William Hamilton)
Philly.com Sports Doc
POSTED: MONDAY, MARCH 24, 2014, 9:40 AM
Baseball and softball may be similar sports, but the injury data differs quite a bit. Let’s see what the research says.
A 2007 paper in the Journal of Athletic Training looked at softball injuries from 1988-2004 using the NCAA injury surveillance system. Over the 16 years of data collection, the rate of injury was 1.6 times higher in games than in practices (4.3 versus 2.7 injuries per 1000 athlete-exposures).
Preseason injury rates were more than double the regular season injury rates.
Postseason injury rates were lower than preseason and in-season rates.
43% of injuries occurred to the lower extremity while 33% were to the upper extremity.
For game injuries, ankle sprains and knee internal derangements accounted for 19% of all injuries.
Concussions accounted for 6% of all game injuries and players were 3 times more likely to sustain a concussion and 2 times more likely to suffer a knee internal derangement in a game versus practice.
Of the three mechanisms of injury, contact with something other than another player accounted for 51% of all game injuries followed by non-contact at 27%. Sliding was the highest mechanism for game injuries at 27% while only accounting for a small percentage of practice injuries. Non-contact injuries accounted for 55% of all practice injuries.
When looking at injury severity, more than 22% of all game and practice injuries required time missed from participation of 10 days or more. Knee internal derangements and ankle ligament sprains accounted for the majority of injuries requiring time away from sports (30.4%).
In games, the base runner, batter, pitcher, and catcher were the positions with the highest risk of injury. (62.3%)
Upper extremity injuries are significantly less common in softball than baseball. This is likely due to the underhand pitching motion for softball which places less stress on the shoulder and elbow. Although injuries such as rotator cuff and labral tears do occur, they are not common in softball. The majority of upper extremity injuries are traumatic injuries to the shoulder wrist and hand such as fractures and dislocations. These traumatic injuries should be evaluated by your athletic trainer who will refer to a sports medicine physician for more server injuries such as dislocations and fractures. Minor injuries such as sprains and strains are usually treated with rest, rehabilitation, and taping/bracing if needed.
Ankle sprains and knee internal derangements are the most common softball injuries. Combined, they account for more than 22% of all injuries requiring 10+ days away from participation. Ankle sprains are the most common injury in softball and are usually the result of sliding into a base. The majority of ankle sprains are minor injuries and can be treated conservatively. Treatment can involve a short time off from play (if needed) with rehabilitation consisting of regaining range of motion/flexibility, strength, and balance. All of this should be done under the guidance of an athletic trainer or physical therapist.
Knee internal derangements are the second most common injury and consist primarily of meniscal tears and ACL tears. Whereas ACL injuries require a surgical consult and are almost always season ending, some athletes are able to finish their season with meniscal tears if they are only mildly symptomatic. Once again, a consultation with an orthopedic surgeon should be made to discuss the severity of the injury and treatment options.
Softball has almost twice as many concussions during games as baseball. This is likely due to the shorter distance to the pitching mound and the smaller infield. The shorter pitching distances may place batters at increased risk of being hit by a pitch. The smaller infield places the players closer to the batter giving less time to react in order to avoid being hit by a batted ball. The smaller infield may also increase the risk of contact with another player. As we have learned from contact sports such as football and hockey, concussions are serious injuries and should be treated as such. An evaluation by a sports medicine clinician trained in concussion assessment should be performed in order to develop an appropriate treatment plan. This may include time away from the classroom as well as from the playing field.
Unlike baseball, lower extremity injuries account for the majority of both minor and severe injuries in softball. As with any injury, players should be evaluated by a sports medicine specialist and an appropriate plan of care should be developed.
Philly Sports Doc
Justin Shaginaw, M.P.T., A.T.C.
Posted: Monday, March 10, 2014
It’s that time of year. Spring sports are in the air, even if the spring weather isn’t. Let’s head to the ballpark and start with baseball.
Upper extremity injuries are the most common area injured for both college and pro baseball players. Shoulder injuries account for approximately 20 percent of all injuries in both pro and college players. These injuries include dislocations, sprains and strains, labral injuries, and rotator cuff injuries.
Stats and facts about baseball injuries
Dislocations are an emergent injury and immediate medical attention should be sought. In the above research studies, injuries diagnosed as sprains and strains were likely either misdiagnosed or players were given this diagnosis to down play the severity of the injury. Sprains and strains are more likely an underlying rotator cuff or labral injury. Both of these are usually the result of a kinetic chain dysfunction, which is like having your car’s steering out of alignment. By correcting the alignment issues, most shoulder problems can be resolved as long as they haven’t passed the point of no return. Once this happens, surgery is usually the only option to truly fix the problem.
Elbow injuries account for approximately 16 percent of pro and 8 percent of college injuries. These injuries include sprains and strains, contusions, and more severe injuries such as ulnar collateral ligament injuries (Tommy John) and posterior impingement. As with the shoulder, elbow injuries diagnosed as sprains and strains were either misdiagnosed or players were given this diagnosis to down play the severity of the injury. Elbow sprains and strains are more likely the precursor to an ulnar collateral injury. And just as in the shoulder, by correcting alignment issues, most elbow problems can be resolved as long as they haven’t passed the point of no return.
Pediatric and early adolescent shoulder and elbow injuries need to be assessed by a physician who specializes in pediatric sports medicine. These injuries can be different than the adult injuries due to open growth plates. Two such examples are little leaguer’s elbow and osteochondritis dissecans (OCD). These injuries are the result of throwing too much and overloading the elbow. This is why pitch counts are so important in little league through high school aged players.
The first step in treating upper extremity problems in a throwing athlete is to be evaluated by a sports medicine clinician who specializes in the assessment of the kinetic chain. These problems include loss of shoulder range of motion (specifically internal rotation), scapular dyskinesia (shoulder blade weakness/abnormal movement), trunk and hip range of motion, core strength/stability, balance, and lower extremity flexibility and strength (specifically hip rotation range of motion and gluteus medius strength).
Rehabilitation is the first step in correcting the underlying kinetic chain issues. Please be aware that not all rehab is the same. An athlete that did rehab and did not get better may not have done the correct rehab. Players should not throw until significant improvement has been made with rehab. In cases where players do not improve with the correct rehab, surgical consultation is the next step if the athlete wants to continue to play.
The 3 main lower extremity injuries in baseball are:
Hand and wrist injuries account for approximately 10 percent of baseball injuries. These can be minor such as contusions to more serious injuries such as fractures and dislocations. The majority of these injuries are from being hit by a pitch or from sliding. Hand and wrist injuries should be evaluated by your athletic trainer who will refer to a sports medicine physician for more server injuries such as dislocations and fractures. Minor injuries are usually treated with rest, rehabilitation, and taping/bracing if needed.
Facial injuries are rare in baseball. When they occur, they are usually the result of being hit by a pitch. Examples of these injuries include facial fractures and eye injuries. These can be very serious and need immediate medical attention.
Other less common injuries seen in baseball include core injuries/sports hernia, back/neck pain, and foot injuries. All of these should be initially evaluated by your athletic trainer who can develop an appropriate rehab plan as these injuries are usually minor and resolve with conservative treatment.
As you can see, upper extremity injuries in baseball are the most common and tend to be the ones that will cause significant time missed from play. The cause of most shoulder and elbow injuries is an underlying kinetic chain problem. Brian Cammarota, MEd, ATC, CSCS, CES, another contributor to the Sports Doc blog, has some great posts on kinetic chain problems, throwing programs, and injury prevention for throwers. Please review some of his posts for further insight into upper extremity injuries in throwers.
Justin Shaginaw, M.P.T., A.T.C.
POSTED: WEDNESDAY, FEBRUARY 5, 2014, 6:00 AM
This is the last blog of a three part series on winter scholastic sports. Let’s head to the mat.
Sprains and strains account for nearly half of all wrestling injuries with the shoulder being more common in high school wrestlers and the knee more common in college. About 40 percent of those injured return to the mat within 1 week.
These injuries should be evaluated by your team’s athletic trainer and appropriate treatment plan developed. This usually includes some time off the mat, rehabilitation exercises (strengthening, stretching, balance, etc), and modalities (heat, ice, etc). For more serious injuries, schedule an appointment with a sports medicine physician for further work up (x-rays, MRI, etc) and other treatment options .
Dislocations/subluxations account for approximately 10% of all wrestling injuries. These are urgent and often times emergent injuries requiring immediate care from an athletic trainer followed by a referral to a sports medicine physician or the emergency room. These injuries most commonly occur to the shoulder, elbow, and patella and require a prolonged period off the mat and rehabilitation.
Lacerations are much more common in college wrestling and account for approximately 10 percent of collegiate injuries. These injuries vary in severity with some being managed by your athletic trainer with an immediate return to practice or the match while others require physician referral for sutures. Suturing may require a period of time off the mat depending on the location.
Fractures are the second most common injury in high school wrestlers accounting for approximately 15 percent of all injuries. These are emergent injuries requiring immediate care from an athletic trainer and referral to a sports medicine physician or the emergency room. Fractures require a significant period of time off the mat and are often season-ending.
Concussions account for approximately 5 percent of injuries for both high school and college wrestlers. The majority of concussions resolve within a week. A small portion will require a prolonged recovery period and may require a significant amount of time away from the sport. All concussions should be taken seriously and evaluated initially by the team’s athletic trainer with a referral to s sports medicine physician trained in evaluation and management of athletic concussions.
Skin infections represented 8.5% and 20.3% of all reported high school and college adverse events respectively.
All wrestlers with a skin infection should be evaluated by a physician for appropriate medical treatment as dictated by National Federation of State High School Associations (NFHS) and the National Collegiate Athletic Association (NCAA). Wrestlers will also need a clearance letter from their physician clearing them to return to practice and competition. There are also prophylactic treatment options for some dermatologic conditions such as herpes which can be prescribed by a physician.
Wrestling injuries are usually due to the combative nature of the sport. As you can see, sprains and strains account for the majority of wrestling injuries. Most of these are minor and can be managed conservatively with a quick return to sports. The above treatment recommendations are just a guideline and any injury should be evaluated by your team’s athletic trainer or a sports medicine physician to accurately diagnose the injury and provide appropriate care.
Justin Shaginaw, M.P.T., A.T.C.
POSTED: WEDNESDAY, FEBRUARY 5, 2014, 6:00 AM
A 2008 article by Yard et al in The American Journal of Sports Medicine calculated rates of injury among high school and college wrestlers during the 2005-2006 season using the High School Reporting Information Online (RIOTM) and the NCAA Injury Surveillance System (ISS). It also characterized the incidence and type injuries and compared risk factors for high school and college wrestling injuries.
There were 387 injuries among participating high school wrestlers during 166,279 athlete-exposures, for an injury rate of 2.33 injuries per 1000 athlete-exposures (AE).
258 injuries occurred among college wrestlers during 35,599 athlete-exposures, for an injury rate of 7.25 injuries per 1000 AE. The injury rate was higher in college than in high school.
Injury rates were higher in matches than in practices for both high school and college.
Strains/sprains accounted for approximately half of all high school (48.1%) and college (49.2%) injuries. The most common high school injury sites were the shoulder (18.6%) and knee (15.4%) while the knee (24.8%), shoulder (17.8%), and head/face (16.6%) were most common in college.
The most frequent high school injuries were:
Philly Sports Doc
Justin Shaginaw, MPT, ATC, Aria 3B Orthopaedic Institute, Athletic Trainer - US Soccer Federation
POSTED: MONDAY, JANUARY 27, 2014, 9:40 AM
My last blog was about basketball injuries. Let’s dive into the pool and talk about common swimming injuries.
Poor swimming mechanics may be a contributing factor in many swimming injuries. But assessing these mechanics is beyond the expertise of most sports medicine. Your swimming stroke should be assessed by your coach, taking into account your specific injury, in order to eliminate an underlying biomechanical cause. A team approach should be taken with swimming injuries incorporating these stroke changes along with a specific rehabilitation program from your athletic trainer or sports medicine provider.
Shoulder/upper arm injuries are the most common body area injured in swimming. These injuries can generally be categorized into two causes: flexibility and strength issues.
From a flexibility stand point, shoulder injuries are usually from being too loose (hypermobile) or too tight (hypomobile). Hypermobility allows the shoulder ball to subtly move around in socket where hypomobility stresses shoulder structures due to lack of flexibility.
Strength issues are usually seen as problems with scapular (shoulder blade) positioning and stability. Shoulder injuries should be thoroughly evaluated by your team’s athletic trainer or a sports medicine specialist to assess the underlying cause of the problem and develop an appropriate treatment plan which may include time out of the pool, rehabilitation, medications, injection, and even surgery when indicated. Common diagnoses include rotator cuff tendonitis/impingement, biceps tendonitis, rotator cuff tear, and labral tear.
Neck and back injuries are the second most common behind the shoulder. Swimming puts significant stress on the spine, specifically rotational stress on the cervical and thoracic spine. Common diagnoses include sprain/strain, spondylolysis, and disc derangement (bulge, herniation, etc).
As with the shoulder, these injuries should be evaluated thoroughly by your team’s athletic trainer or a sports medicine specialist to assess the problem and develop an appropriate treatment plan which usually includes time out of the pool, rehabilitation, and medication.
Hip pain is an uncommon problem in swimming and is more frequently associated with the breast stroke due to the rotational motion of the kick. Some common diagnoses for hip pain in swimmers include sprain/strain, femoral acetabular impingement, and labral injuries. As with the shoulder, these injuries can generally be categorized into two causes: flexibility (hyper or hypomobility) and strength issues. Your team’s athletic trainer should assess the injury and either provide an appropriate rehabilitation program or refer the athlete to a sports medicine physician for further evaluation and treatment options.
Patellofemoral pain is another uncommon problem in swimming. It is also known as anterior knee pain or chondromalacia and its main symptom is pain behind the knee cap. More common in females than males, patellofemoral pain is usually the result of overuse from the kicking motion involved in swimming.
The first line of treatment is an evaluation by your team’s athletic trainer to put together an appropriate rehabilitation program including lower extremity stretching and strengthening. It may also require some time out of the water to allow the symptoms to subside. Patellofemoral pain from swimming is of a different etiology than weight-bearing sports where the underlying problem is a biomechanical/kinetic chain dysfunction.
Hand and wrist injuries are relatively uncommon in swimming. They include finger sprains/fractures from contact with the wall and overuse injuries of the elbow and wrist such as sprains/strains and tendonitis. Finger injuries should be evaluated by your athletic trainer and referred to a sports medicine physician if a fracture is suspected. Overuse injuries are usually the result of overtraining or poor swimming mechanics. These injuries should also be evaluated by your athletic trainer. Treatment may include time out of the pool, rehabilitation, and referral to a sports medicine specialist if indicated.
As you can see, upper extremity injuries account for the majority of swimming injuries. Many of these are minor and can be managed conservatively with a quick return to sports. The above treatment recommendations are just a guideline and any injury should be evaluated by your team’s athletic trainer or a sports medicine physician to accurately diagnose the injury and provide appropriate care.
Swimming injury prevention brochure from the STOP (Sports Trauma and Overuse Prevention) Sports Injuries program:
Philly.com Sports Doc
Justin Shaginaw, MPT, ATC, Aria 3B Orthopaedic Institute, Athletic Trainer - US Soccer Federation
Robert Senior, Sports Doc blog Editor
Posted: Monday, January 13, 2014, 6:00 AM
The winter sports season is in full swing. In gyms everywhere the squeak of basketball shoes on the court can be heard. Along with the layups and 3 pointers, there are common injuries that occur. Let’s talk about some of these common basketball injuries and the appropriate treatment.
This is the most common injury in basketball, accounting for 24.6 percent of women’s game injuries and 26.2 percent for men. It occurs when the foot rolls inward spraining the ligaments on the outside of the ankle. Swelling and bruising often occur with the severity of the injury dictating the athlete’s ability to return to play.
Mild ankle sprains can return fairly quickly, sometimes even in the same game with taping or a brace. More serve injuries can take weeks to months to recover. Immediate treatment involves immobilization and ice followed by range of motion, strengthening, and balance/proprioceptive exercises. For athletes that cannot bear weight on their foot, they should be put on crutches and see a physician to rule out a fracture as well as assess the extent of the injury. For prevention, taping and bracing has been shown to reduce the rate of ankle injuries in sports.
Stress injuries (shin splints, stress fracture, etc) are another common basketball injury, usually seen during preseason as athletes transition from softer outdoor fields in fall sports to the hard indoor courts. Initially, symptoms are only with activity. As the problem worsens, pain can occur with walking and even at rest. If not addressed early, it can lead to a stress fracture requiring the patient to stop sports for a prolonged period of time.
The common locations of these injuries are the tibia, medial malleolus, fifth metatarsal, and navicular. Initial treatment involves decreasing impact activities until symptoms resolve and assessing the athlete’s feet for appropriate shoes and possibly supportive inserts. It’s also a good idea to progress practice intensity gradually to allow players to acclimate to the new playing surface. Players that do not respond to conservative measures should be seen by a sports medicine physician for further evaluation.
Knee injuries are the second most common injury in basketball, with ACL injuries being more common in female players. Both meniscal tears and ACL injuries are caused by deceleration and pivoting on a planted foot. The common signs of an internal knee injury include swelling and a feeling of a “pop” or “catching and locking.” Immediate treatment should include ice and crutches if the athlete cannot walk normally followed by a referral to a sports medicine doctor to diagnose the injury.
Research has shown that ACL prevention programs have been effective in reducing the incidence of injury. Some well-known programs are the PEP program (http://smsmf.org/smsf-programs/pep-program), Sportsmetrics (http://sportsmetrics.org/), and the FIFA 11+ program (http://f-marc.com/11plus/home/) . Although some of these are sports specific, they can be easily modified for basketball.
Commonly known as patellar tendonitis or jumper’s knee, this injury presents as pain and tenderness of the patellar tendon. The mechanism of injury is believed to be due to repetitive strain to the tendon from jumping, cutting, and deceleration activities involved in basketball. Treatment includes limiting activity until symptoms improve, as well as ice, quad stretching, eccentric quadriceps exercises, and soft tissue treatments. Patellar tendon straps can also be beneficial. In more chronic cases, medications, injection therapies, and surgery are other options.
In younger patients whose growth plates are not closed, usually under 15, Osgood-Schlatter syndrome is more common. This is an injury to the attachment of the patellar tendon to the tibia. The tendon actually pulls away from the bone causing a boney protuberance that can become painful and tender. The treatment for Osgood-Schlatter syndrome is rest and ice as it is almost always self-limiting.
Finger injuries are fairly common in basketball and occur when players “jam” their fingers on the ball. The injuries are usually simple sprains that can be treated symptomatically with ice and buddy taping. Occasionally these injuries can be more serious such a fracture and tendon rupture. If the player’s finger looks deformed or if they are unable to move it, they should be evaluated by a sports medicine physician to accurately diagnose the injury.
Shoulder injuries are relatively rare in basketball with the most common being dislocations and labral tears. These injuries usually occur when a player is blocked during a shot forcing the arm backwards. For a dislocation, urgent treatment should be sought from the team’s athletic trainer and a physician if necessary. Labral tears should be considered for players with chronic shoulder pain with overhead activities such as shooting, and an appointment with a sports medicine physician should be schedule to accurately diagnose the injury.
The other upper extremity injury seen in basketball is a fracture. These usually occur from falling on an outstretched arm. As with dislocations, the player should be evaluated by the team’s athletic trainer and referred to a physician for urgent care.
As you can see, lower extremity injuries account for the majority of basketball injuries. Many of these are minor and can be managed conservatively with a quick return to sports. With more serious injuries such as ligament/tendon ruptures and fractures, urgent care by a sports medicine physician is advised. The above treatment recommendations are just a guideline and any injury should be evaluated by your team’s athletic trainer or a sports medicine physician to accurately diagnose the injury and provide appropriate care.
The most recent information on Marcus Lattimore's knee injury is that he sustained a knee dislocation without fracture. This is a devastating injury for a high level athlete and likely jeopardizes his chances to play professionally. Knee dislocations are a complex injury requiring precise diagnosis of which structures are injured and subsequent surgical procedure/procedures to reconstruct and repair the involved structures. By definition, a knee dislocation involves at least 3 of the 4 main ligaments in the knee. The injuries sustained in a knee dislocation can include the cruciate (ACL, PCL) and collateral ligaments (MCL, LCL), posterolateral corner, menisci, articular cartilage, fractures, and vascular injuries just to name a few. Most of the the research on these injuries involve significant traumatic injuries such as automobile accidents. There are few papers on return to sports following knee dislocation.
Hirschmann MT published an article in 2010 in the American Journal of Sports Medicine titled "Surgical Treatment of the Complex Bicruciate Knee Ligament Injuries in Elite Athletes: What Long-term Outcome Can we Expect?" The results showed that only 8 of 24 athletes returned to their pre-injury level of sports activity. This is dramatically different from isolated ACL injuries where almost all athletes return to their pre-injury level of play. The athletes that had the best outcomes had early, open, complete single stage surgery. Luckily Marcus will have the best care possible increasing his odds for a full recovery. I am hoping that he proves the statistics wrong with a return to his football career.