After the Eagles announced Carson Wentz would undergo surgery to reconstruct a torn ACL, everyone is wondering when he can play again. This is the first question athletes ask me after ACL surgery and my answer is always, “when you’re ready.”
Athletes want a definitive time frame but that’s nearly impossible to give. Return to play is extremely individual and needs to be based on achieving objective, measurable goals and not an arbitrary time frame.
In the past, sports medicine professionals would give an estimated time frame, often six months, for return to play. But research and clinical experience has shown that athletes rarely fit into arbitrary time frames. Returning too soon following ACL reconstruction can put an athlete at high risk for re-injury or injuring the opposite knee. A 2016 study published in the British Journal of Sports showed that athletes returning to play prior to nine months had as high as a 40 percent re-injury rate. More importantly, athletes who passed an objective-based return to play testing battery reduced their re-injury risk to only 6 percent.
So, what is an objective-based return to play testing battery? There is still debate on which tests are most effective at teasing out any deficits or limitations that would predispose an athlete to re-injury, but most research supports assessing balance, strength, and the athlete’s ability to hop. I I developed a return to practice battery that I have been using for over five years and my unpublished data shows a significant reduction in re-injury rates for the athletes who have passed all aspects of testing. The battery assesses balance, strength, power, hopping, and landing mechanics using simple clinic-based tests and incorporating newer technology such as force plates and 2-D video analysis. This test also helps the athlete return to their pre-injury level of performance.
The last part of the process is the progressive return-to-practice programming. Athletes need to slowly progress activity from simple, straight drills to higher-level cutting and pivoting. They need to progress from non-contact to contact practice. There is also a newer term in sports medicine called acute/chronic work load. This simply means not increasing training load too quickly and not returning a player until they have reached their pre-injury training loads. Professional sports have high-tech ways of measuring this such as GPS tracking and heart rate monitoring where we use more lo tech monitoring for athletes who don’t have access to GPS monitoring
Returning to play following ACL reconstruction is a measurable process based on testing and training data. The Eagles will base Wentz’s return on these objective criteria. Eagles fans can be confident that Wentz will be back on the field, at or near his pre-injury performance level, for pre-season next August.
OCTOBER 28, 2016
In Sunday’s Eagles game against the Minnesota Vikings, cornerback Ron Brooks went down with a non-contact right knee injury in the first half. The Eagles have confirmed that he suffered a ruptured quadriceps tendon that will require surgery, making it likely that he will be out for the season.
Quadriceps tendon injuries occur when the tendon tears away from the patella (knee cap). It typically result from a forceful eccentric load where the muscle is resisting bending of the knee. They commonly occur in males over 40 during sporting activities or resulting from a fall. Other potential non-traumatic causes include tendinosis, use of corticosteroids, or the use of specific antibiotics (fluoroquinolones). However, this injury is very rare in football.
While Achilles tendon ruptures are becoming more frequent in the NFL, ruptures to the quadriceps tendon are hardly seen. A 2013 study by Boublik in the American Journal of Sports Medicine looked at quadriceps tendon ruptures in the NFL over a 10-year period starting in 1994. During that time, the study found only 14 quad tendon ruptures in 10 years. By comparison, NFL injury rates for Achilles tendon ruptures are between 4-10 per year with the 2015-16 season seeing more than 15.
The injury can vary in severity from a small partial tear that heals without surgery, to a larger partial tear or complete rupture, both of which require surgery.
Recovery from a ruptured quadriceps tendon can be difficult, particularly for professional athletes. There are many factors that can influence return to play including partial versus complete tear, age of the player, years in the league, and pre-jury performance (starter vs substitute).
Boublik et al found in their studies that only 50 percent of the athletes with this injury returned to play. By comparison, 80 percent of athletes return to play after a patellar tendon rupture, while another study by Parekh et al in 2009 found that 70 percent of Achilles tendon ruptures return sports.
Only time will tell if Ron Brooks will return to his pre-injury level of play. Hopefully, he will prove the statistics wrong.
February 11, 2016
We all know someone who has torn their ACL. The vast majority of these athletes have surgery to reconstruct the ACL and return to their previous level of activity. However, we know that there is a high incidence of arthritis in patients who tear their ACL, whether or not they have surgery. Research studies show that anywhere from 10% to 90% of people show some level of post-traumatic arthritis following ACL injuries. This large variation is due the degree of arthritic changes that were used as the cutoff in studies. Barenius et al American Journal of Sports Medicine 2014 showed that ACL reconstructed knees had a 3 times greater incidence of post-traumatic arthritis regardless of graft type using a grade of 2 or greater on the Kellgren-Lawrence (Scale is 0-4 with grade 2 showing significant osteophytes and/or cartilage reduction up to 50%). They also showed an even greater incidence of arthritis in patients with combined ACL and meniscus injuries. Why is this? Isn’t an ACL reconstruction supposed to fix the knee and prevent arthritis?
An ACL reconstruction will not prevent arthritis. The surgery is done to regain stability of the knee to prevent further injury to the meniscus and articular cartilage due to episodes of the knee giving way. Research is still trying to figure out the definitive cause of post-traumatic arthritis in order to effectively minimize or potentially eliminate it. Currently, we break down the potential causes into two groups: time of the injury and post-surgical. Time of the injury factors include the “bone bruise”, inflammation, and meniscal injury. Nearly all ACL injuries show a bone bruise on MRI. Research has indicated that this bruise results in damage to the articular cartilage and underlying subchondral bone. The theory is that over time, this damage progresses and eventually results in post-traumatic arthritis. Inflammation from the initial injury results in a catabolic inflammatory process causing abnormal tissue remodeling and damage. Meniscal injury has shown to be the greatest predictor of future arthritic changes. Bindle et al Journal of Athletic Training 2001 showed that as little as a 10% loss of meniscus volume may increase tibiofemoral contact pressure by 65 %. Potential post-surgical factors include altered knee kinematics, inflammation, and inadequate rehabilitation. Altered gait kinematics are seen in the reconstructed knee as compared to the uninvolved knee. These altered kinematics result in an abnormal shift of contact pressures and is likely to contribute to the development of post-traumatic arthritis. Post-surgical inflammation not only negatively effects the knee cartilage as mentioned above, it can potentially cause surgical tunnel widening resulting in ACL graft laxity which may further alter knee kinematics. Lastly, inadequate rehabilitation may have an effect on arthritis as well. Not fully regaining range of motion and strength as well as not fully normalizing gait and movement patterns may negatively alter knee kinematics.
You may be wondering, why the concern about post-traumatic arthritis? I’ll just get a knee replacement when I’m older, right? The concern is for the patients that develop significant and symptomatic arthritis at a younger age. Nebelung et Arthroscopy 2005 found that in a group of elite athletes who underwent ACL reconstruction, all had degenerative changes by 35 years and 42 % had undergone a total knee replacement. These patients had significant symptoms and functional limitations requiring knee replacement. Obviously, they were no longer able to participate in sports and had difficulty at work and with daily activities. As we continue to narrow down on the cause/causes of post-traumatic arthritis in order to better manage, and hopefully eliminate it, we must continue to council athletes on the long term complications of ACL injury and the best evidence in managing these injuries.
Posted: Tuesday September 22, 2015
We’ve all heard the news that Kiko Alonso injured his left ACL Sunday against Dallas. This is the same knee that he had reconstructed last July. The internet is saying he has a partial tear, while Les Bowen states that it’s a grade 2 sprain. Alonso is to meet with Dr. James Andrews for a second opinion. What exactly is his injury? Is it a partial tear or a sprain? And what does this mean for this season?
A ligament strain is a partial tear. There is a spectrum of sprain/tear from very mild with no laxity, or looseness, to a complete tear. Partial ACL injuries come down to how stable, or loose, the knee is and whether the athlete can play without instability/giving way. Typically, a grade 2 injury stretches the ligament to the point where it becomes loose. This is usually referred to as a partial tear.
An MRI is helpful to see if the reconstructed ACL is injured but can’t assess the degree of laxity/looseness. The stability of the knee is best assessed with a physical examination. Often times, a device called a KT 1000 is used to give an objective measurement of the looseness. Generally, if the involved knee has more than 3-4 mm difference compared to the uninjured side the knee will be unstable.
However, if the ACL laxity is within an acceptable range, rehab may allow the athlete to return without surgery. We call these athletes “copers” as they are able to function with a lax ACL. However, most athletes with a partial ACL injury are unable to return to cutting and pivoting sports without surgery. Another thing to consider is that this is Alonso’s 3rd ACL injury which may mean he is predisposed to repeat injuries.
As we await the results for Alonso’s second opinion with Dr. Andrews, let’s hope he has a stable, partial tear with only minimal laxity. This would give him the best shot at returning this season.
Philly.com Sports Doc
Posted: Friday, March 13, 2015, 10:16 AM
Sam Bradford. (Photo by Streeter Lecka/Getty Images)
All the sports buzz in Philly this week is revolving around the Sam Bradford trade. Is he a good QB? Don’t ask me, but ACLs are something I know about.
His first ACL injury was to his left knee in October 2013. From the video, it looked like it was a contact injury where he was pulled down from behind. It appeared that his foot got caught with a flexion rotation mechanism of injury. He injured the same knee this past August, which also looked like a contact injury from a direct blow to the knee causing hyperextension.
As we know, there are two types of ACL injury mechanisms, contact and non-contact. Contact injuries like Bradford’s are usually more bad luck than pre-disposition. If he tore them running in the open field I would be more concerned about predisposition.
That being said, statistically, he is at high risk for re-injury, according to the research.
A study published in Arthroscopy in 2005 found that 12% of patients re-injure their same knee or injure their other knee in the first five years following surgery. Another study published in the British Journal of Sports Medicine 2006 found that soccer players with a previous ACL reconstruction had at least four times the risk of re-injury or injuring their other knee. Numerous research articles show continued deficits in strength and lower extremity control that can persist for years following ACL reconstruction. If you’ve followed ACL injuries in professional athletes, not everyone recovers as quickly as Adrian Peterson. Many end up like Derrick Rose and RG III.
An article published in Orthopedics 2014 by Erickson titled “Performance and Return-to-Sport After ACL Reconstruction in NFL Quarterbacks” looked at 13 NFL quarterbacks who underwent ACL reconstruction. They concluded that there is a high rate of return to sport in the NFL for quarterbacks and that performance was not significantly different from pre-injury. Another study published in the American Journal of Sports Medicine in 2010 found that only 63% of NFL players returned to play in approximately 11 months after surgery. More experienced and established athletes are more likely to return to competition at the same level than those with less professional experience. Being selected in the first 4 rounds of the NFL draft was highly predictive of return to play (Bradford was the number 1 pick in 2010).
An article published in the American Journal of Sports Medicine in 2009 showed that a history of meniscus surgery, but not ACL reconstruction shortens the expected career in NFL players. They also concluded that a combination of ACL reconstruction and meniscus surgery might be more detrimental to an athlete’s durability than either surgery alone.
There is a high rate of re-injury or injury to the other knee in patients following ACL reconstruction. NFL players in general show about a 63% return to play after ACL reconstruction. However, quarterbacks showed not only a high rate of return to play but a return to previous levels of performance. That said, we don’t know for sure if other structures were injured in the knee that could affect his return to play. From a research standpoint, the odds are in Bradford’s favor to be back to the player he was prior to his injuries. But the question to be answered is, will he be AP or RG III?
Philly.com Sports Doc
POSTED: TUESDAY, NOVEMBER 25, 2014
If you’re a power lifter or body builder, please stop reading. If you’re a high level athlete, please read with an open mind. Now for the rest of us… My patients ask me all of the time, “What can I do in the gym?” For me, it’s not what you can and can’t do but what you should or shouldn't do.
Why do I say that? Here are just a few of the injuries we've seen in the office from doing the wrong things in the gym: a middle aged women who tore her ACL doing jumping jacks onto a plyometric box, a 60 year old who tore his meniscus when he was forced into deep knee flexion during yoga, and a broken tibia from the bar hitting her leg during Olympic lifting. It’s not that some people can’t do these things; it’s just that most of us shouldn't be doing them.
Here are my top 5 things you should avoid at the gym.
1. Deep squats
I always have this debate with strength and conditioning coaches. Why do they have their athletes squat past 90 with resistance? It’s not functional except for maybe wrestlers and football lineman, and even with them, is it worth the risk of injury? For the rest of us who are just trying to stay in shape it is a recipe for knee pain and meniscus tears. Deep squats put significant strain on the knee ligaments, significant pressure on your patellofemoral joint (knee cap), and it puts your meniscus at significant risk for tearing.
Let’s talk about the meniscus tear more specifically. As we squat down, the knee not only flexes but the femur glides posteriorly on the tibia. From about 90 degrees and beyond, we are putting almost all of the pressure on the posterior horn of the meniscus. Now just add a little rotation and pop, there goes your meniscus. And we know that our menisci start to degenerate over time (starting at about 35-40) placing us at even greater risk for a meniscus tear. Do the theoretical benefits of deep squatting out weigh the risks, absolutely not! So let’s please stop at 90 degrees.
2. Dead lifts
This is another exercise where I also debate people on the risk/benefit of the exercise. Yes, it’s a great exercise to strengthen your hip extensors (glutes and hamstrings) but it’s an even better way to injure your back. Repetitive flexion activities have been shown to be a significant factor in back injuries, specifically bulging and herniated disks. Even if you perform the exercise with perfect mechanics, which none of us do all the time, you’re still setting yourself up for a problem. Just like the meniscus in the knee, the discs in the spine start to degenerate with age. Combine this with an exercise that puts significant strain on the posterior annulus of the disc and you’re in for a lifetime of intermittent back pain. Instead of dead lifts, let’s focus on exercises that will still strengthen your hip extensors with less risk of injury. Lunges, step ups, bridging, and squats above 90 can all accomplish this while limiting the risk of low back injury.
3. Overhead presses
Overhead military press, dumbbell shoulder press, etc., all put your rotator cuff at risk for injury. Every time we lift our arms over head we have the potential for some impingement of our rotator cuff under our acromion. Now add weight and we’re just tempting fate. There is also a common theme with all these problematic exercises I’m writing about: our tissue starts to wear down and degenerate with age.
This is once again true for the rotator cuff. So why do an exercise to strengthen our shoulders that puts our rotator cuff at significant risk for injury? If you want to strengthen your deltoid you just need to do some pushing and pulling exercises. Overhead exercises aren't functional and the risk of injury just isn't worth it. Don’t try to “isolate” your shoulders and instead strengthen them functionally with pushing and pulling exercises such as push-ups and incline pull-ups on the smith press or TRX.
4. Bench press to your chest
I don’t like the bench press because it’s not a functional exercise, but that’s another discussion. The risk with bench press is that when your elbows break the plane of your chest, you’re putting significant strain on the stabilizing structures of the shoulder, specifically the labrum and capsule. Now add heavy weight and it’s a labral tear waiting to happen. And like everything else, the labrum degenerates over time. Clicking in your shoulder? It’s probably a labral tear. If you have to bench, keep the weight reasonable and don’t let your elbows break the plane of your chest. Better yet, do a standing cable column press as it is a much more functional position; just don’t go too deep and your shoulders will thank you.
5. Anything with heavy weights
I’ll be the first to admit that I loved lifting heavy weights when I wrestled in college. It was always a competition of who could bench and squat more. Looking back, bench pressing did nothing for me as a wrestler as I should have been doing more pulling exercises. After two shoulder surgeries, a hip labral tear which has likely progressed to arthritis (no MRI as I don’t want to know), focal arthritis in my knee as well numerous other chronic injuries, my joints wish I had focused on functional training and not weight lifting.
There is starting to be a paradigm shift in the strength and conditioning world. People are turning away from weight lifting and focusing on functional training and injury prevention. Stanford University’s director of football sports performance Shannon Turley is on the forefront of this movement. Instead of having freshman players hit the weight room when they get to school, they focus on regaining flexibility, improving core stability, and relearning correct movement patterns. He has had to write letters to NFL scouts about his program and why his players don’t have a record setting combine bench press but excel on the field and are injury free.
EXOS, formerly Athlete’s Performance, is the provider for strength and conditioning for the Men’s U.S. National Soccer team. Their approach to sports performance is to fix an athlete’s problems/weaknesses. There is little return in trying to improve quad strength in soccer players who already have super strong quads. Instead, you’ll see more gains by focusing on correcting their weaknesses such as limited hip mobility and glute med weakness. Even though we’re not professional athletes, let’s take a page out of their training programs and try to fix our deficits such as flexibility, core strength, and movement patterns and leave the heavy weights on the rack.
As I’m writing this, I’m envisioning the comments that I’ll be getting. But as I always tell my patients, “Is it better to look good or to feel good?” Let’s move away from working out the way we always have and start thinking about our long term health, as many of the exercises we do are counterproductive to our overall goal of living a healthy, happy, and pain free life.
Philly.com Sports Doc
Posted Monday, October 20, 2014
If you didn’t see it live, I’m sure you’ve seen the video of New York Giants' Victor Cruz’s knee injury. He wasn’t tackled. His knee didn’t twist in some abnormal way. How did he tear his tendon on such a routine play?
Patellar tendon ruptures are a rare injury. A 2011 study in the American Journal of Sports Medicine showed that there were only 21 isolated patellar tendon ruptures over a ten year period from 1994-2004. This study showed an 80% return to play in the NFL following surgery. The big question is even with a return to football, will he be the same player he was before surgery?
The mechanism of injury is still debatable. Research shows that it takes a force of approximately 17 times body weight to tear the patellar tendon which is why this is such an uncommon injury. In sports, it appears to be the result of an eccentric flexion load followed by forceful knee extension. If you watch Cruz’s injury closely, it appears that his knee is flexing under his body weight as he forcefully tries to push off to catch the pass. The eccentric loading combined with the concentric push off likely created an extreme amount of strain on the tendon resulting in rupture. (Get a rehash of injury here)
Patellar tendon rupture requires an immediate repair of the torn tendon. The type of surgery performed is dictated by where the tendon tore and if the tendon tissue is healthy. If the tendon tore in the middle, the two ends are sewn back together. If the tendon tore closer to the bone, it can be sutured back down. If the tissue is not healthy, i.e. chronic patellar tendonitis, the repair can be augmented with a cadaver graft.
Rehab involves a period of immobilization followed by rehabilitation to regain range of motion and strength. Players are usually braced for approximately 6 weeks following surgery. During this time there is a gradual progression of knee flexion range of motion to allow the tendon to heal while trying to limit the amount of post-operative stiffness that will occur. Over the next 4-5 months rehab focuses on regaining full flexibility and strength with gradual progression to sports activities such as running, agility exercises, and plyometrics. Return to sports usually takes a minimum of 6 months.
As the NFL study showed, 80 percent of players return to football, but their definition of return to play was participating in one regular season NFL game. There is a big difference between playing in one NFL game and returning to pro bowl level of play. Only time will tell if Cruz will be celebrating touchdown receptions with his salsa dance next season.
Philly.com Sports Doc
Posted: Monday, May 12, 2014, 9:37 AM
Unlike other collegiate sports, there have been no studies published on track and field injuries using the NCAA injury surveillance system. Therefore, we will look at the few studies that analyze injury prevalence in track and field.
A 2005 article published by Zemper in the journal Medicine and Sports Science suggested that 70-80 percent of all track and field injuries are the result of running events. 75 percent of all injuries are to the lower extremity and the overwhelming majority of injuries occur during practice. A 2011 article by Jacobsson et al in the American Journal of Sports Medicine showed a strong dominance of overuse-related conditions such as tendinopathies and stress fractures in track and field athletes.
These overuse injuries account from 60-90 percent of injuries in various published papers. An article by Alonso et al in 2012’s British Journal of Sports Medicine looked at track and field injuries during the period of the Daegu 2011 IAAF World Championships. Sprint events accounted for 27.7% of all injuries followed by long distance at 17.3%, and jump events at 14.1%.
Let’s look at the some of the different events and the injuries that go along with them.
Sprints and Relays
The most common injury in sprint events is muscle strain, specifically hamstring strain. The mechanism of hamstring injuries is still being debated. These include neuromuscular inhibition, eccentric overload, over-striding, and decreased muscular endurance to name a few. To simplify hamstring injuries, these can be broken down into acute and chronic injuries.
Acute hamstring injuries are the result of a distinct injury such as a sprinter pulling out of a race. These usually involved a tear of the hamstring muscle. These can be minor or more serve where bruising, swelling, and a defect are noted. Hamstring injuries can result in significant time away from training and competition, and early return frequently results in re-injury. Treatment involves management of pain in the acute phase of injury followed by rehabilitation to regain ROM, strength, and eccentric control prior to initiating a running program.
Chronic hamstring pain can be due to a variety of underlying causes. These include incomplete rehabilitation from a previous hamstring injury, overuse injury, and referred pain from other areas such as the lumbar spine. A thorough evaluation from an athletic trainer or physical therapist is needed to determine the underlying cause and to develop an appropriate rehab program.
Middle distance injuries are a combination of sprint injuries and distance injuries. The event distance and the training methods will dictate which type of injury is more likely to occur. As with any injury, the athlete should be evaluated by the team’s athletic trainer in order to develop an appropriate rehab program.
Unlike sprints, long distance injuries are primarily overuse and repetitive stress injuries. These include sprains, strains, and tendinopathies as well as stress fractures, shin splints, and exertional compartment syndrome. Treatment should not only focus on resolving the symptoms but also include a thorough biomechanical evaluation to correct the underlying cause. This should include assessment of footwear, lower extremity alignment, and lower extremity flexibility and strength. This may also include modification of the athletes training program with decreases in frequency, intensity, and/or duration.
Hurdles and Steeple Chase
Hurdles and steeple chase have injuries similar to the above running events but also include more traumatic injuries. With hurdles, injuries can occur from hitting the hurdle or from catching a hurdle resulting in a fall or awkward landing. Steeple chase injuries can occur from stepping onto the obstacle, not clearing the obstacle, or landing from/over the obstacle.
Traumatic injuries can include contusions, ligament sprains, knee internal derangements (meniscus tear, ACL injury) and fractures. These injuries should be evaluated by the team’s athletic trainer and treated accordingly or referred to a sports medicine physician for more serious injuries. These more serious injuries usually require significant time away from training and competition.
Long jump and triple jump
Long jump and triple jump are horizontal jumping events with specific associated injuries. These injuries can be broken down into overuse and traumatic. Overuse injures include tendinopathies and repetitive stress injuries as seen in other events and should be treated as noted previously. Traumatic injuries occur either at takeoff or landing and can include fractures, acute muscle tears, dislocations, serious ligament sprains (such as ankle sprains), tendon ruptures, and knee internal derangements. These more serious injuries should be evaluated by your team’s athletic trainer and referred to a sports medicine physician for appropriate care. These more serious injuries usually require significant time away from training and competition.
High Jump and Pole Vault
High jump and pole vault are vertical jumping events with similar injuries to horizontal jumping events. These injuries can also be broken down into overuse and traumatic. Besides the traumatic injuries noted for long and triple jump, pole vault accounts for almost all of the catastrophic injuries (fatal, non-fatal but causing permanent severe functional disability) and serious (no permanent disability, but a severe injury). These more serious injuries should be evaluated by your athletic trainer and referred to a sports medicine physician for appropriate care. These injuries usually require significant time away from training and competition.
Javelin, shot put, hammer, and discus
Throwing events account for the vast majority of upper extremity injuries in track and field. These include injuries to the rotator cuff and shoulder labrum as well as abdominal injuries from the rotational throws, and lower extremity injuries from planting during a throw. One injury specific to the javelin is an ulnar collateral ligament tear (Tommy John injury).
UCL injuries in javelin are due to the throwing motion and the stress incurred at the elbow, similar to baseball. Throwing injuries need to be evaluated by the team’s athletic trainer and either treated conservatively through rest and rehabilitation or referred to a sports medicine physician when more a more serious injury occurs such as an ulnar collateral ligament tear.
Exertional heat illness
Lastly, environmental factors can cause heat related illness in track and field athletes. Athletes, coaches, and medical staff need to be aware of the environmental conditions (heat and humidity) and monitor athletes for any signs or symptoms of heat illness. Heat illness is an urgent and sometimes emergent issue and needs to be address by the event’s medical staff. Signs and symptoms can include finding it hard or impossible to keep playing, loss of coordination, dizziness or fainting, profuse sweating or pale skin, headache, nausea, vomiting or diarrhea, and stomach/intestinal cramps or persistent muscle cramps.
To truly evaluate an athlete for heat related injury, an accurate core body temperature needs to be assessed by a trained medical professional such as an athletic trainer. Cooling measures should be implemented with the best method being ice immersion. For those athletes with a core temperature over 104° and showing signs or symptoms of heat illness, immediate cooling should be implemented and emergency response should be initiated as heat stroke is likely.
The National Athletic Trainers Association has an excellent web page on How to recognize, prevent, & treat exertional heat illness: http://www.nata.org/nr072606
As you can see, not only do we see lower extremity injuries in track and field, we also see upper extremity injuries and environment injuries such as exertional heat illness. Although most of the injuries are minor, there are urgent and emergent injuries in track and field and these are best managed by the team’s athletic trainer and medical staff.
Philly.com Sports Doc
Posted: Monday, April 28, 2014
A 2007 study by Dick et al in the Journal of Athletic Training looked at injury rates for the women’s lacrosse using the NCAA injury surveillance system from 1988-2004.
The results show the game injury rate was twice the rate for practice (7.15 versus 3.30 injuries per 1000 athlete-exposures [A-Es]). Preseason practice injury rates were almost twice as high as regular-season practice rates. More than 60% of all game and practice injuries were to the lower extremity.
Approximately 22 percent of all game injuries and 12 percent of all practice injuries involved the head and neck. In games, ankle ligament sprains (22.6%), knee internal derangement (14.0%), concussions (9.8%), and upper leg muscle strains (7.2%) accounted for the majority of injuries.
In practices, ankle ligament sprains accounted for the largest proportion of all injuries (15.5%), followed by upper leg muscle strains (11.7%) and knee internal derangements (6.1%).
Participants had almost 5 times the risk of sustaining a concussion or a knee internal derangement during a game compared with practice and 3 times the risk of sustaining an ankle ligament sprain during a game. The greatest proportion of game injuries (44.3%) resulted from no direct contact. A total of 35.9 percent of game injuries were associated with other contact (primarily stick or ball) and 18.6 percent with player contact. The majority of practice injuries (62.0%) involved a non-contact mechanism. A total of 22 percent of game and 24 percent of practice injuries were severe enough to restrict participation for at least 10 days. In games, knee internal derangements accounted for almost half of all severe injuries, followed by ankle ligament sprains. Head injuries represented 7 percent of the severe game injuries. In practices, lower leg stress fractures, knee internal derangements, and ankle ligament sprains were the primary severe injuries.
Lower extremity injuries account for over 60 percent of all collegiate women’s lacrosse injuries. The majority of these injuries can be divided into the following diagnoses: ankle sprains, knee internal derangements, upper leg strains, and lower leg stress injuries.
Ankle sprains account for 22.6 percent of game and 15.5 percent of practice injuries. These are primarily lateral ankle sprains which are caused by the ankle rolling inward during cutting and pivoting. Most ankle sprains are minor and players can return quickly to practice and competition. These injuries should initially be evaluated by your team’s athletic trainer. Depending on the severity, players with minor injuries may return immediately with taping or bracing. More severe injuries may require time away from the sport and more substantial treatment including evaluation by a sports medicine physician and subsequent rehab. There may be a period of immobilization and limited weight bearing depending on the extent of the injury. Rehab involves regaining range of motion and flexibility, strength, and balance with a gradual progression to full sports activities.
Knee internal derangements account for 14 percent of game and 6.1 percent of practice injuries. The two most common diagnoses are ACL tears and meniscal tears. In women’s lacrosse, ACL injuries account for a great number of knee internal derangement due to the significantly higher rate of ACL injury in female athletes compared to males. Both meniscus tears and ACL tears are serious injuries and should be evaluated by a sports medicine physician. Although most of these injuries require surgery, there are some players who can finish the season. If an athlete is to finish the season with one of these injuries, she needs to undergo a structured rehabilitation program and meet specific objective goals before being cleared to return to sports.
Upper leg strains account for 7.2 percent of games; 11.7 percent of practice injuries. These injuries are primarily hamstring strains. Hamstring injuries can be difficult to treat and there is still debate on the best course of treatment. In my experience, the initial phase of treatment focuses on reducing pain and inflammation while regaining flexibility. The second phase involves regaining strength in the injured and initiating lower level sport specific activities. The final phase involves higher level sport specific activities and a structured return to sport progression.
6.5 percent of practice injuries involve lower extremity stress injuries. These can include stress reaction or exertional compartment syndrome, which combined are commonly called shin splints, as well as stress fractures. Lower extremity stress injuries are almost always due to repetitive overload stress. This can be caused by increased training loads in under conditioned athletes, overtraining, lower extremity biomechanical issues, or a combination of all three. The first treatment is to reduce the volume and/or intensity of training. At times, athletes need to be shut down depending on the severity of symptoms.
These injuries should be evaluated by both the athlete’s athletic trainer and a sports medicine physician to rule out more serious diagnoses such as a stress fracture. The athlete should also have a biomechanical analysis performed to help correct any underlying dysfunction that may be contributing to the problem such as over pronation or weak gluteus medius.
Concussions are the 3rd most common game injury and 6th most common practice injury in collegiate women’s lacrosse. In this study, concussions resulted in 7 percent of all injuries requiring greater than 10 days of missed time. This correlates with concussion research showing that that most concussions resolve within that time frame. 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.
Upper Extremity Injuries
Upper extremity injuries in women’s lacrosse account for less than 1 percent of all injuries and therefore were not tabulated in this study. This is likely due to the rules that prohibit checking in women’s lacrosse.
As you can see, ankle sprains and knee internal derangements (ACL tears and meniscus tears) are the two most common injuries followed by upper leg muscle-tendon strains (hamstrings) and concussions. Upper extremity injuries are uncommon in women’s lacrosse. Any injury should be evaluated by your athletic trainer to assess the severity of the injury and determine the appropriate plan of care.
(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.