CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

PART 1ANKLE AND FOOT INJURIES
Sprain of the lateral ankle ligaments is a very common injury. Approximately
25000 people experience it each day in the U.S., and 6000 people a day in France.
A sprained ankle can happen to athletes and non-athletes, children and adults. It
can happen when people take part in sports and physical ﬁtness activities, or when
they simply step on an uneven surface, or step down at an angle. In 2/3 of cases, thedegree of sprain is mild or moderate, grade 1 or 2. Ankle injuries constitute 25% of
all sports-related injuries, including 21% to 53% of basketball injuries and 17% to
29% of all soccer injuries.
The evaluation of ankle injuries can be simpliﬁed by understanding how
anatomic factors dictate speciﬁc injury patterns. The high number of recurrent
sprains and the frequency of long-term complications from instability and arthritis
suggest that the current management protocols may not be always optimal. Athletes
often return too quickly to the sports arena before their rehabilitation is complete.
Athletes and coaches, as well as some physiotherapists and physicians, often fail toappreciate the risk of recurrent injury or chronic disability. The pressure exerted on
the practitioner by athletes and coaches to return athletes to play as soon as possible
must be balanced with the need to ensure complete recovery.
A. Anatomy and Biomechanics

The ankle joint is a simple hinge joint between the leg and the foot. The bonesof the leg (tibia and ﬁbula) form a sort of slot and the curved top bone of the foot(talus) ﬁts between them. The talus is held to the tibia and ﬁbula by ligaments.
Each ligament is a semi-elastic structure and is made of many strands of collagenﬁbres. The ligaments of the ankle hold the ankle bones and joint in position. They
protect the ankle joint from abnormal movements—especially twisting, turning, androlling of the foot. Ligaments usually stretch within their limits, and then go back totheir normal positions. When a ligament is forced to stretch beyond its normal range,a sprain occurs. A severe sprain causes actual tearing of the elastic ﬁbres.
The ligament on the inside of the ankle (superﬁcial and deep deltoid ligaments)
has two layers; the deepest one is most important. The lateral ligament is made upof three separate bands: one at the front (anterior talo-ﬁbular ligament: ATFL), one
in the middle (calcaneo-ﬁbular ligament: CFL) and one at the back (posterior taloﬁbular ligament: PTFL). The front band is the ligament usually injured in sprains ortears of the ankle ligaments, and the middle band is sometimes affected.
The stability of the talo-crural joint depends on both joint congruency andthe supporting ligamentous structures. The lateral ankle ligaments (Figure 101a), responsible for resistance against inversion and internal rotation stress, are
the ATFL, the CFL, and PTFL. The deltoid ligaments, which are responsible forresistance to eversion and external rotation stress, are less commonly injured.
However, an injury to these ligaments indicates severe trauma.

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

Fibulotalocalcaneal ligament

Tibia

Interosseous
membraneTransverse
tibiofibular
ligament

Posteriortibiofibular
ligament

Deltoidligament

Calcaneofibular
ligament

Subtalarjoint

Calcaneus

Anterior talofibular ligament

Posteriortalofibular
ligament

Interosseous talocalcaneal
ligament
Cervical ligament

Lateral talocalcaneal
ligament

Calcaneofibular
ligament(a)(b)

Figure 10-1. Lateral (a) and syndesmotic (b) ligaments of the ankle.

The ATFL resists ankle inversion in plantar ﬂexion, and the CFL resists ankle
inversion during dorsiﬂexion. The CFL spans both the lateral ankle joint and lateralsubtalar joint, thus contributing to both ankle and subtalar joint stability. The PTFL
is under greatest strain in ankle dorsiﬂexion and acts to limit posterior talar displacement within the mortise as well as talar external rotation.
The calcaneus articulates with the talus above it by three facets, to form thesubtalar joint. The subtalar joint controls foot supination and pronation in close
conjunction with the transverse tarsal joints of the midfoot. The CFL provides
stability to inversion and torsional stresses to both the ankle and subtalar joints. Up
to 50% of apparent ankle inversion observed actually comes from the subtalar joint.
The CFL, the cervical ligament, the interosseous ligament, the lateral talocalcaneal
ligament, the ﬁbulotalocalcaneal ligament (ligament of Rouviere), and the extensor
retinaculum contribute to stability of the subtalar joint.
The tibia and ﬁbula have a small joint between themselves just above the ankle(tibio-ﬁbular ligaments). The syndesmotic ligaments, responsible for maintaining
stability between the distal ﬁbula and tibia, consist of the anterior tibioﬁbular
ligament, the posterior tibioﬁbular ligament, the transverse tibioﬁbular ligament, theinterosseous ligament, and the interosseous membrane (Figure 10-1b). Injuries to theankle syndesmosis occur as a result of forced external rotation of the foot or during
internal rotation of the tibia on a planted foot.
The ligament at the front is involved in 10–20% of ankle sprains; the ligament
at the back, like the deltoid ligament, is mainly damaged in association with severe
fractures of the ankle bones.
Clinically, the most commonly sprained ankle ligament is the ATFL, followed by
the CFL.
B. Mechanisms of Injuries

Lateral ankle sprains occur as a result of landing on a plantar ﬂexed andinverted foot. These injuries occur while running on uneven terrain, stepping in ahole, stepping on another athlete’s foot during play, or landing from a jump in an

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

unbalanced position. When this happens, the full force of the body’s movementis placed on the anterior talo-ﬁbular ligament. This may stretch, with tearing ofsome of its ﬁbres (sprain) or it may tear completely. If there is a major injury of theanterior talo-ﬁbular ligament, the forces transfer to the calcaneo-ﬁbular ligament andthe tibio-ﬁbular ligaments, which may also be sprained or torn. Occasionally small
pieces of bone may be torn off with the ligaments.
In a few cases, a twisting force on the ankle may cause other damage. The bones
around the ankle may be broken, a piece of the joint surface inside the ankle may bechipped off, ligaments connecting other bones in the foot may be sprained or torn, or
the tendons around the ankle may be damaged.
C. Patient History

Given the strong correlation between the mechanism of injury and diagnosis,
identifying the joint position at the time of injury is a useful ﬁrst step in the clinicalevaluation. Therefore, it may be clearer if the examiner shows the patient what ismeant by the various terms or has the patient demonstrate the mechanism of injury
with the uninjured ankle.
Revisiting the precipitating activity may help determine if the injury was unavoidable or resulted from inherent weaknesses. Jumping and landing on anotherathlete’s foot or stepping in a rut on the ﬁeld is likely to injure a previously normal
ankle. Sprains that are unprovoked or occur in situations that wouldn’t injure a normal
ankle raise concerns for other diagnoses, such as tarsal coalition, osteochondritis, orperoneal tendon dislocation.
The history should include the location of pain, presence of swelling, andfunctional capacity, including the ability to bear weight, walk, run, and jump. The
history should also include whether the patient heard a “pop” and a review of priorinjuries, previous diagnostic studies, treatments, and any residual impairments.
The patient’s current sports participation history and training plan help to gauge
conditioning needs during recovery and requirements for return to play.
D. Physical Examination

The exam of the injured ankle starts with an assessment of the degree and locationof swelling and ecchymosis. Palpation should include bony landmarks such as thelateral malleolus, the medial malleolus, the ﬁbula, the ﬁfth metatarsal, and, in skeletally immature patients, the physis. Achilles tendon, peroneal tendons, and posterior tibial
tendon should also be palpated, because injuries to these structures may mimic ankle
sprains. Soft-tissue palpation includes the ATFL, CFL, PTFL, deltoid ligament, andperoneal tendon. Tenderness over the anterior joint line or syndesmosis may indicate asprain of the interosseous membrane.
A careful neurologic examination is essential to rule out loss of sensation or
motor weakness, as peroneal nerve and tibial nerve injuries are sometimes seen withsevere lateral ankle sprains.

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

Provocative tests for lateral ankle instability include the anterior drawer test,
inversion stress test, and the suction sign. The anterior drawer test is speciﬁc for the
ATFL and can be done with minimal pain or guarding. Two provocative tests forsyndesmotic ligament injury are the squeeze test and the external rotation stress test.
Tests for range of motion, strength, and proprioception are likely to be abnormal
in the acute setting but may help assess deﬁcits in patients who have chronic orrecurrent sprains.
1. Grading
Various systems are used for grading the severity of ankle sprains. It is cumbersome to assign a grade 1 to 3 rating to each of the three lateral ligaments that may
be injured. Some clinicians prefer to use the number of injured lateral ligaments toassess severity. An isolated sprain to the ATFL is considered a grade 1 (mild) sprain.
A two-ligament injury involving the ATFL and CFL is a grade 2 (moderate) sprain.
A grade 3 (severe) sprain indicates all three lateral ligaments have been injured.
Alternatively, grading is more commonly determined by the extent of functional
disability. Grading of ankle sprains guides treatment, rehabilitation, and prognosis:
a. Grade 1 sprain: Slight stretching and some damage to the ﬁbres (ﬁbrils)of the ligament.
b. Grade 2 sprain: Partial tearing of the ligament. If the ankle joint is
examined and moved in certain ways, abnormal looseness (laxity) of theankle joint occurs.
c. Grade 3 sprain: Complete tear of the ligament. If the examiner pulls or
pushes on the ankle joint in certain movements, gross instability occurs.
E. Radiologic Evaluation

The decision to order radiographic studies should be based on the probabilityof ﬁnding bony abnormalities. When radiographs are indicated, the standard views
should include anteroposterior, lateral, oblique and mortise. The Ottawa clinicaldecision rules (for patient from age 15 to 60 years old) were proposed as a means
to reduce the number of unnecessary radiographic studies without sacriﬁcing
sensitivity for detecting fractures. These guidelines state that an ankle radiographic
series should be obtained if bone tenderness is present over the lateral or medial
malleolus, or if the patient is unable to bear weight for four steps both immediately
post-injury and in the emergency department. Exclusions for use of the Ottawa
ankle rules are age younger than 15 years, older than 60 years, intoxication, multiple
painful injuries, pregnancy, head injury, or diminished sensation due to neurologic
deﬁcit. X-rays are least likely to be warranted for patients who exhibit laxity of
the ATFL without other clinical ﬁndings. Bone scans, magnetic resonance images(MRIs), computed tomography (CT) scans, and arthrograms all have diagnostic
utility for speciﬁc injuries (fractures; avulsions; talar dome fracture) but have little
role in the initial evaluation of ankle sprains.

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

Foot radiographs should also be obtained if the physical examination demonstrates tenderness in the hindfoot, midfoot, or forefoot.
1. Stress Radiographs
Stress radiographs help document lateral ligamentous chronic ankle injury—
especially chronic instability but are not required to make the diagnosis of an acuteankle sprain.
F. Early Treatment

Ligamentous injuries undergo a series of phases during the healing process:hemorrhage and inﬂammation, ﬁbroblastic proliferation, collagen protein formation,and collagen maturation. The more severe the ligament injury, the greater the timerequired to progress through the stages of healing. Early mobilisation of joints
following ligamentous injury actually stimulates collagen bundle orientation andpromotes healing, although full ligamentous strength is not re-established for several
months. Therefore, early treatment focuses on regaining range of motion while
protecting the injured ligaments against re-injury. Limiting soft-tissue effusion
speeds healing.
The standard early treatment following an acute ankle sprain is PRICE(protection, rest, ice, compression, and elevation). Cryotherapy, compression, andelevation are essential to limit initial swelling from hematoma and oedema aroundthe ankle and speed ligamentous healing. Early use of cryotherapy, applied in theform of ice bags, a cold whirlpool, or a commercially available compressive cuff
ﬁlled with circulating coolant, has been shown to enable patients to return to full
activity more quickly. Compression can be applied by means of an elastic bandage,
felt doughnut, neoprene or elastic orthosis, or pneumatic device.
1. Early Mobilisation
Protected weight bearing with an orthosis is allowed, with weight bearing totolerance as soon as possible following injury.
2. Bracing
Protection of the ankle during initial healing is essential. This may be accomplishedwith taping, a lace-up splint, a thermoplastic ankle stirrup splint, a functional walking
orthosis, or a short leg cast. Flexible and semi-ﬂexible braces have been shown toeffectively limit ankle inversion and to resist passive torque. More severe injuries usuallyrequire longer immobilisation. Early protected range of motion in a ﬂexible or semi-rigid
orthosis is superior to rigid cast immobilisation in terms of patient satisfaction, return ofmotion and strength, and earlier return to function.
3. Rehabilitation (see also Chapter 9, Part 2, Principles of Rehabilitation of the
Injured Athlete)
Physical therapy of the injured ankle is divided into 5 phases by some authors:acute, subacute, rehabilitative, functional, and prophylactic; or into 3 phases

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

by others: Phase 1 is rest, ice, compression, and elevation (RICE) and protected
weight bearing as needed. Phase 2 consists of restoring ankle motion, strength, andproprioception and can begin when the patient can place some weight on the ankle.
Phase 3 includes activity-speciﬁc drills before return to full activity.
With the 5 phases protocol, the exact timing of each phase varies with theseverity of the sprain. The acute phase is based on PRICE with goals to limit
effusion, reduce pain, and protect from further injury. The subacute phase focuses
on decreasing and eliminating pain, increasing pain-free range of motion, continuing
protection against re-injury with bracing, limiting loss of strength with isometric
exercises, and continuing modalities to decrease effusion. The rehabilitative
phase emphasises regaining full pain-free motion with joint mobilisation andstretching, increasing strength with isotonic and isokinetic exercises, and employing
proprioceptive training. The functional phase focuses on sports-speciﬁc exerciseswith a goal of returning the patient to sports participation. The prophylactic phaseseeks to prevent recurrence of injury through preventive strengthening, functional
proprioceptive drills, and prophylactic support as needed.
With the 3 phases protocol to mobilise and rehabilitate grades 1 and 2 sprains:
a. Phase 1
Phase 1 is directed toward reducing swelling, protecting the injured
ligaments, and beginning weight-bearing activity. Ice, compression, andelevation may be used to control swelling. The ankle can be protected in a
ﬁgure-eight brace, tape, ankle corset, or cast boot, depending on the severityof injury. The level of protection should allow the patient to begin weightbearing as soon as possible. Crutches may be necessary for pain-freeambulation in some patients, but prolonged immobilisation or non-weightbearing (NWB) have little beneﬁt and, arguably, may have adverse effects on
the patient’s recovery.
b. Phase 2
Phase 2 begins when the swelling has subsided and the patient isambulating without discomfort. The goal of phase 2 is to restore ankle rangeof motion and build strength in the surrounding muscles—particularly theperoneals. Active range-of-motion exercises include drawing the letters of
the alphabet with the toes. Restoring full dorsiﬂexion is critical for regaining
speed, explosiveness, and jumping ability. Dorsiﬂexion can be tested byhaving the patient do a one-legged squat with the heel touching the ground.
Dorsiﬂexion of the uninjured ankle can be used for comparison.
Strengthening can be done with isometric exercises, manual resistance,or elastic tubing exercises. The peroneals compensate for laxity in the lateral
ligaments and should be emphasised in the strengthening programme. Pain or
swelling associated with the exercises indicates that the patient is not readyfor this phase of rehabilitation. When the resistance and number of repetitions
performed with the injured ankle is equal to the uninjured side, the patient
can progress to phase 3 of rehabilitation.

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

In the latter parts of phase 2 and early parts of phase 3, most athletes areable to tolerate low-impact exercise.
c. Phase 3
Phase 3 exercises commence when joint motion and strength are back tonormal. The goal of the early part of phase 3 is to restore the proprioreceptionthat is predictably lost with ankle sprains. Proprioceptive deﬁcits may be
increased by prolonged NWB or immobilisation and may lead to further
injury if not corrected. Proprioception can be measured by a modiﬁed Romberg
test. The patient’s ability to maintain balance on one foot is compared with theuninjured side. Proprioception can be restored by use of a balance board or
exercises such as playing catch or brushing teeth while balancing on one foot.
Braces or tape may be helpful, in part because of their proprioceptive input.
Late Phase 3: at the end of the third phase of rehabilitation comes the readaptation period to prepare the athlete to return to the ﬁeld. This period
consists of functional progression from rehabilitation exercises to sport-speciﬁcskills. When all of the earlier phases have been completed, the patient may
begin a return-to-running program that starts with jogging and progresses torunning, sprinting, circles, ﬁgure eights, cutting, pivoting, and jumping. When
all of these activities can be done without pain or limitation, the patient may becleared to return to practice and, eventually, full participation.
Protection with taping or bracing during daily activity is recommended
until strength returns to normal. When the patient is ready to start the functional
progression, protective devices are recommended only during exercise and sports
participation.
Compliance with and efﬁcacy of the rehabilitation programme may be enhanced
if the patient is able to work with a certiﬁed athletic trainer or physical therapist.
When a course of rehabilitation is prescribed during the initial evaluation of the
injury, many important details of later care may be lost. Contact with a physician,physical therapist, or trainer during each of the three phases of rehabilitation canhelp ensure that patients are progressing at a reasonable rate and correctly performing exercises appropriate for their level of recovery. A well-designed rehabilitation
programme includes a clear plan for implementation, monitoring, and follow-up
care.
G. Non-surgical Treatment Results

Primary surgical repair of the torn lateral ankle ligaments has been advocatedby some as treatment for elite athletes and young adults; however, it has not been
supported in comparative studies that recommend early non-operative functional
treatment of ankle ligament injuries.
It has been documented that satisfactory subjective and clinical stability havebeen restored with non-operative treatments such as casting, taping, bracing, andearly physical therapy. A prospective study of 146 patients with grade 3 ankle
sprains who were randomised into operative or non-operative groups found that

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

the group treated with an ankle orthosis for 6 weeks returned to work faster. No
difference in joint laxity between the groups was found on stress radiographs
performed 2 years post-injury.
Syndesmotic ligamentous injuries without fracture or gross widening of theankle mortise are treated non-operatively with a short leg cast or brace, followed byphysical therapy. The patient should be advised that these injuries result in longer
periods of disability than injuries to the lateral collateral ligaments. If diastasis of
the syndesmosis is evident on plain radiographs, operative stabilisation of the ankle
mortise is accomplished with a syndesmotic screw.
H. Evaluating Chronic Symptoms

Chronic pain following ankle injury is common. In a retrospective study of 457
patients treated with immobilisation or bracing, 72.6% reported residual symptoms
at 6 to 18 months.
In the evaluation process, the workup should center on whether the patient’s
chief chronic ankle complaint is pain or instability (Figure 10-2). If the primary
problem is ankle pain, a concentrated effort should be made to rule out occult
fracture of the foot or ankle. A technetium bone scan is an excellent screening test
to rule out occult fractures and to guide further treatment. If the bone scan reveals
increased uptake in a discrete area, a spot radiograph or computed tomographyscan is useful to further identify the exact location of fracture. Occult or associatedinjuries to the tendons of the foot and ankle should also be considered, and MRI is
the most useful exam to identify and conﬁrm them. Table 10-1 lists some commonly
missed occult fractures and tendon pathologies.
Table 10-1. Commonly missed diagnoses in patientswith chronic ankle pain.
Fractures• Talar dome osteochondral• Lateral talar process• Anterior process calcaneal• Lateral malleolar• Posterolateral distal ﬁbular ﬂake
• Fifth metatarsal base
• NavicularTendon Injuries• Achilles rupture• Peroneal tendon rupture• Peroneal tendon subluxation/dislocation• Posterior tibial tendon rupture• Anterior tibial tendon rupture• Flexor hallucis longus tendon rupture

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

Main problem is instability

Main problem is pain

Stress views

Positive

Negative

Localised bone or
joint tenderness

Localised tendon
tenderness

Poorly localised
tenderness

Surgicalreconstruction

Rehabilitation andproprioception
exercises forfunctional instability

Spot radiographs,
consider CT

MRI

Bone scan

Positive

Treat tendon
tears
Positive forfracture: Treatwith cast or ORIF

Suspicious
for OCDCT or MRI

Negative

Consider MRI
or diagnostic
injections ofsymptomatic
joint

Negative

Positive

Negative

Go to “Spot radiographs, consider CT”
box (at left, under“Localised bone or joint
tenderness” column

Treat
symptoms

Negative
Positive for OCD:
Arthroscopic
debridement and/or
bone grafting

Positive: Treat softtissue impingementwith arthroscopic
debridement

Figure 10-2. Algorithm for chronic ankle pain and instability.
OCD = osteochondritis dissecans; ORIF = open reduction and internal ﬁxation

1. Other Soft Tissue Causes
Other soft-tissue causes of chronic ankle pain include anterolateral ankle
impingement (meniscoid lesion), anteroinferior tibioﬁbular ligament impingement(Basset’s ligament), and anomalous peroneal pathology. Injury to the lateralankle ligaments may produce scarring of the ATFL and joint capsule, leading
to the formation of “meniscoid tissue” in the anterolateral ankle. Anterolateral
impingement can develop when inﬂamed tissue is pinched between the talus, ﬁbula,and tibia. The distal fascicle of the anteroinferior tibioﬁbular ligament may abradethe anterolateral surface of the talus when the ankle is dorsiﬂexed during abnormal
anterior translation of the talus. An anomalous or accessory peroneal tendon may
also cause chronic posterolateral ankle pain.
2. Osteochondral Fractures
Fractures of the talar dome, which occur in association with ankle sprains, arecommonly overlooked. These occur when there is a compressive component to
the inversion injury, especially when landing from a jump. Usually the fracture is

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

not detected initially and the patient presents some time later complaining of an
unremitting ache in the ankle, despite appropriate treatment for an ankle sprain.
A radioisotopic bone scan will conﬁrm the presence of an osteochondral
fracture. Grade II, III and IV will be evident on a CT scan, but only MRI will pickup a grade I lesion. Grade I and II should be treated with a NWB cast for 6 to 8
weeks. Grade IIa, III and IV fractures require arthroscopic removal of the fragment.
A comprehensive rehabilitation programme with a graduated return to weightbearing is then required.
3. Tibialis Posterior Tendonitis
Tibial posterior tendonitis (Figure 10-3) is the most common cause of medial ankle
pain. This condition may occur as a result of prolonged stretching into eversion andis often associated with excessive subtalar pronation. Treatment with physiotherapy,
NSAIDs, and orthotics may be required to control excessive pronation.
Posteriortibialis
tendonTalus
Navicular

Calcaneus

Figure 10-3. Tibialis posterior tendonitis—excess pronation puts additional
stress (arrow) on this tendon.

4. Flexor Hallucis Longus Tendonitis
Flexor hallucis longus tendonitis presents with pain on toe-off or forefoot weightbearing. It is aggravated by resisted ﬂexion of the ﬁrst toe or stretch into full dorsiﬂexion of the hallux. This condition is often associated with posterior impingement
syndrome as the FHL tendon lies in a ﬁbro-osseous tunnel between the lateral andmedial tubercles of the posterior process of the talus. Treatment consists of physiotherapy, NSAIDs, and stretches.
5. Tarsal Tunnel Syndrome
This syndrome occurs as a result of entrapment of the posterior tibial
nerve in the tarsal tunnel where the nerve winds around the medial malleolus.
This syndrome often occurs as a result of trauma (inversion injury to the ankle) or
overuse associated with excessive pronation. Features of this condition are pain
radiating into the arch of the foot, heel and toes, and pins and needles and numbness
on the sole of the foot aggravated by prolonged standing, walking or running.
Treatment may consist of corticosteroid injection and control of excessive pronation
by orthotics.

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

6. Medial Malleolus
Stress fracture of the medial malleolus should also be considered in the runningathlete with persistent medial ankle pain.
7. Lateral Pain
Lateral pain is generally associated with a biomechanical abnormality, and canhave a variety of causes:
a. Peroneal Tendonitis
Peroneal tendonitis (Figure 10-4) is the most common overuse injury
causing lateral ankle pain. Inﬂammation of the peroneal tendons or sheaths
may be due to excessive eversion (running on slopes, etc.) and is commonly
associated with excessive pronation. Localised tenderness over the peroneal
tendons is occasionally associated with swelling and crepitus. Treatment
consists of physiotherapy, assessment of biomechanical abnormalities andcorrection.
Peroneus brevis
Peroneus longus
FibulaSuperior peroneal
retinaculum
Inferior peroneal
retinaculum
Figure 10-4. Lateral view of peroneal tendons and support structures.

b. Sinus Tarsi Syndrome
The calcaneus and the talus articulate via three facet joints and are supported by several surroundign ligaments to form the subtalar join (see A. Anatomyb. Sinus Tarsi Syndrome
The calcaneus and the talus articulate via three facet joints and are supported by several surrounding ligaments to form the subtalar joint (see A. Anatomy
and Biomechanics). Injuries to this complex may result in the “sinus tarsi
syndrome.” This syndrome is often due to poor biomechanics and chronic
overuse, or results from an acute ankle sprain. It often occurs after repeatedforced eversion (e.g. high jump take-off). Forced passive eversion of thesubtalar joint elicits pain and the subtalar joint is often stiff. Treatment includes
mobilising the subtalar joint, NSAID, and biomechanical correction. Local
anesthetic injections may also be required.

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

8. Anterior Ankle Pain
Anterior ankle pain related to overuse is usually due to:a. Tibialis Anterior Tendonitis
Tibialis anterior tendonitis presents as localised tenderness, crepitus andpain on resisted dorsiﬂexion. It is usually due to restriction in joint ROM or
downhill running. Treatment requires NSAID, physiotherapy and mobilisationof the ankle joint.
b. Anterior Impingement
Anterior impingement of the ankle may be the cause of chronic ankle painor may follow an ankle sprain. As a result of persistent forced dorsiﬂexion(kicking), exostoses develop on the anterior margins of the ankle joint. As
they become larger they impinge on overlying soft tissue and cause pain.
Pain is reproduced by standing and lunging forwards (positive anterior
impingement test). X-ray with a “hinge” view will identify the bony spurs.
Treatment of mild cases involves AP glides of the talo-crural joint at the end
range of dorsiﬂexion. Corticosteroid inﬁltration can be an effective treatment
in more severe cases. Surgery to excise larger exostoses may be required.
9. Instability
If the primary problem is ankle instability, the patient will experience feelingsof “giving way” of the ankle on uneven ground, inability to play cutting or jumping
sports, loss of conﬁdence in ankle support, reliance on braces, and a history ofmultiple ankle sprains. If, on further evaluation, stress radiographs are positive formechanical lateral ligamentous laxity, surgery is indicated to reconstruct the loose
ligaments.
If stress radiographs are nondiagnostic for mechanical laxity, the patient may
have functional ankle instability due to deﬁcient neuromuscular control of the ankle,
impaired proprioception, and peroneal weakness. Treatment in this case should bedirected toward restoring peroneal tendon strength and ankle motion and improving
ankle proprioception with physical therapy. Other causes of instability, not demonstrated by stress radiographs, include rotational instability of the talus, subtalar instability,
distal syndesmotic (tibioﬁbular) instability, and hindfoot varus malalignment.
I. Treatment Options: Surgical

Surgical treatment for ankle sprains is rare. Surgery is reserved for injuries thatfail to respond to non-surgical treatment, and for persistent instability after monthsof rehabilitation and non-surgical treatment.
The patient continues to experience multiple episodes of lateral ankle instability,
and mechanical problems are documented by stress radiographs. Most proceduresare designed to tighten or reconstruct the ATFL and CFL.
Surgical options include:• Arthroscopy: A surgeon looks inside the joint to see if there are any loose
fragments of bone or cartilage, or part of the ligament caught in the joint.

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

• Reconstruction: A surgeon repairs the torn ligament with stitches or
sutures, or uses other ligaments and/or tendons found in the foot and aroundthe ankle to repair the damaged ligaments
Following lateral ankle ligamentous reconstruction, most postoperative regimens
immobilise the ankle in a cast for 4 weeks followed by an orthosis for an additional
4 weeks. Physical therapy with an emphasis on peroneal strengthening and propioceptive training is instituted 6 to 8 weeks after surgery. Return to sports occurs at
about 3 months postsurgery.
1. Rehabilitation After Surgery
Rehabilitation after surgery involves time and attention to restore strengthand range of motion so the athlete can return to pre-injury function. The length oftime one can expect to spend recovering depends upon the extent of injury and theamount of surgery that was done. Rehabilitation may take from weeks to months.
2. Rehabilitation Exercises
Rehabilitation is used to help to decrease pain and swelling and to prevent
chronic ankle problems. At ﬁrst, rehabilitation exercises may involve active rangeof motion or controlled movements of the ankle joint without resistance. Water
exercises may be used if land-based strengthening exercises, such as toe-raising,are too painful. Lower extremity exercises and endurance activities are added as
tolerated. Proprioception training is very important, as poor proprioception is amajor cause of repeat sprain and an unstable ankle joint. Once the patient is painfree, other exercises may be added, such as agility drills. The goal is to increase
strength and range of motion as balance improves over time.
Speciﬁc exercises for competitive athletes would probably use more intensive
strengthening and proprioceptive exercises. Exercise bands are available fromsupply houses. Grade 1 ankle sprain don’t need a rehabilitation programme.
The exercise protocol for grade 2: 3 times per week, for 9 to 15 sessions
depending on the progression of symptoms. Physiotherapy methods are useful
but no one is preferable. Ultra-sound is not useful. The most important thing is torecover an active mobility in the sagittal plane in a painless range of motion. The
movements should be done slowly and controlled to reap the full beneﬁts. Patientsare encouraged to discontinue using crutches or canes as soon as pain will allow.
Walking is permitted to the limits of pain. Proprioception exercises begin between
10 and 15 days after the disappearance of pain and with a good mobility of theankle.
The next phase of rehabilitation is agility drills and sport-speciﬁc drills thatshould be guided by a healthcare professional.
J. Risk Factors/Prevention

The best way to prevent ankle sprains is to maintain good strength, muscle
balance, and ﬂexibility.

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

•
•
•
•

Warm-up before doing exercises and vigourous activities.
Pay attention to the surfaces on which one runs, walks, or works.
Wear good shoes.
Pay attention to the body’s warning signs to slow down when feelingpain or fatigue.

K. Foot Injuries

1. Rear-foot
The most common causes of rear foot pain are:a. Plantar Fasciitis
The plantar fascia is a dense ﬁbrous membrane that extends the entire
length of the foot, from the calcaneal tubercle to the proximal phalanges.
It protects the underside of the foot and helps support the arches (Figure10-5).
Plantar fasciitis is a degenerative
condition of the plantar aponeurosis.
It is caused by repetitive microtrauma
as part of an overuse syndrome.
Predisposing factors may beanatomic, such as pes cavus or pes
Plantar fascia
planus, leg length discrepancy, or
excessive pronation; or biomechanical,
such as poor foot gear, muscle tightness,
Area of tenderness
nerve entrapment, or over-training.
Pain occurs on initial standing, as the
Calcaneus
plantar fascia contracts during sleep. On
examination, there is usually point tenderFigure 10-5. Plantar fasciitis.
ness at the medial calcaneal tuberosity.
Treatment is primarily non-surgical.
Analgesics such as NSAIDs help tocontrol pain. Properly ﬁtted and cushioned foot gear is essential, along withorthoses when needed.
Dorsiﬂexion night splints prevent contraction of the plantar fascia during
sleep, and are an effective adjunct. Stretching the gastrocnemius and soleus,
as well as the toes, is an important part of the treatment regimen. Wallstretches and the use of slant and rocker boards aid in dynamic stretching.
Corticosteroid injections may relieve pain rapidly, but increase the risk of
tendon rupture and fat pad atrophy. Delivering corticosteroids by iontophoresis
is safer, but the effects may be short-lived. The use of extra-corporeal shock
wave therapy (ESWT) has been espoused in recent years as treatment for awide variety of tendinoses, including plantar fasciitis. However, results remain
controversial due to a variety of factors. For recalcitrant cases, endoscopicfascial release has been proposed as a safer approach than open surgery,although not all patients become pain-free.
b. Fat Pad Contusion
This type of contusion occurs as an acute injury after a fall onto the heel orchronically as a result of excessive heel strike, such as long jumping. Treatment
consists of avoiding aggravating activities, and strapping. A padded heel cup is
helpful for jumpers.
c. Calcaneal Stress Fractures
These stress fractures can be shown with a radioisotopic bone scan and need
NWB for 6 weeks.
2. Midfoot
The most important causes of midfoot pain are:a. Navicular Stress Fracture
It is important to diagnose this condition, as signiﬁcant morbidity is
associated with non-union. Dorsal foot pain and pain and tenderness over thenavicular are clinically suggestive. Isotopic bone scan and follow-up CT scan
are required for complete diagnosis. Treatment requires a molded cast with
NWB for 6 to 8 weeks. Tenderness over the “N-spot” must have subsided
for a clinical clearance, and mobilisation of the stiff ankle and foot is essential
after the cast is removed.
b. Extensor Tendonitis
Extensor tendonitis will cause an ache over the dorsal aspect of the midfoot and insertion of tibialis anterior. The extensor tendons may be weakened
and strengthening is essential.
c. Midtarsal Joint Sprains
These joint pains happen occasionally, especially when instability of thefoot is present. In particular, the calcaneonavicular ligament may be injured.
3. Forefoot
Forefoot pain can be caused by:a. Metatarsal Stress Fractures
The athlete complains of fore-foot pain, aggravated by running or weightbearing activities. The neck of the second metatarsal is the most common siteof pain. A bone scan may be needed to conﬁrm the diagnosis.
The most difﬁcult fractures to manage are those at the base of the second
metatarsal, the proximal shaft of the ﬁfth metatarsal, and the sesamoid bones.
The base of the second metatarsal can be treated with a NWB cast for 4 to
6 weeks, but occasionally may require internal ﬁxation if non-union occurs.
Most sesamoid fractures heal if rested, but may go on to avascular necrosis if
neglected.
Acute inversion injury of the foot may cause avulsion of the peroneal brevis
tendon, or fracture of the proximal shaft of the ﬁfth metatarsal (Jones fracture).

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

This fracture often results in non-union. It requires a NWB cast for 4 to 6
weeks, or internal ﬁxation if casting fails.
b. First Metatarsophalangeal Joint Sprain
This sprain occurs as a result of excessive forced dorsiﬂexion of the ﬁrst
MTP joint, and is referred to as “turf toe”. There is a history of vigourous“bending” at the ﬁrst MTP joint, with pain on movement. The injury
involves a sprain of the plantar capsule and ligament. Physiotherapy andorthotic correction may be required.
c. Sesamoid Injuries
Sesamoid injuries can include traumatic fracture, stress fracture, and sprainof a bipartite sesamoid. These are usually associated with marked tenderness
and swelling in the sesamoid region. The patient will often walk with theirweight borne laterally to compensate. Physiotherapy, padding to distribute theweight, and corticosteroid injections can all be effective.
References

1.

2.

3.
4.

5.

6.

7.
8.
9.

AAOS. Sprained ankle. American Academy of Orthopaedic Surgeons.
Codeveloped by the American Orthopaedic Foot and Ankle Society, March
2005. Accessed on website http://www.aaos.org/ on 8 August 2005.
Anderson, S. J. Acute ankle sprains. Keys to diagnosis and return to play.
Phys. and Sportsmed. 30(12), 2002. Accessed on website www.physsportmed.
com on 10 August 2005.
Braun, B. L. Effects of ankle sprain in a general clinic population 6 to 18
months after medical evaluation. Arch. Fam. Med. 8(2):143-148, 1999.
British Orthopaedic Foot Surgery Society. Ankle instability. Blackburn
Orthopaedic Foot and Ankle Service. On website: www.bofss.org.uk, accessedon 10 August 2005.
Cawley, P. W., and E. P. France. Biomechanics of the lateral ligaments of theankle: an evaluation of the effects of axial load and single plane motion on
ligament strain patterns. Foot Ankle 12(2):92-99, 1991.
DiGiovanni B. F., D. A. Nawoczenski, M. E. Lintal, et al. Tissue-speciﬁcplantar fascia stretching exercise enhances outcomes in patients with chronicheel pain: a prospective randomized study. J. Bone Joint Surg. Am. 85(7):12701277, 2003.
Garrick, J. G. The frequency of injury, mechanism of injury, and epidemiologyof ankle sprains. Am. J. Sports Med. 5(6):241-242, 1977.
Garrick, J. G., and R. K. Requa. The epidemiology of foot and ankle injuries
in sports. Clin. Sports Med. 7(1):29-36, 1988.
Hartsell, H. D., and S. J. Spaulding. Effectiveness of external orthotic support
on passive soft tissue resistance of the chronically unstable ankle. Foot Ankle
Int. 18(3):144-150, 1997.

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

10. Hockenbury, R. T, and G. J. Sammarco. Evaluation and treatment of ankle
sprains, clinical recommendations for a positive outcome. Phys. and Sportsmed.
29(2), 2001. On website www.physspotsmed.com, accessed on 10 August 2005.
11. Povacz, P., S. F. Unger, W. K. Miller, et al. A randomized, prospective studyof operative and non-operative treatment of injuries of the ﬁbular collateral
ligaments of the ankle. J. Bone Joint Surg. Am. 80(3):345-351, 1998.
12. Regis D., M. Montanari, B. Magnon, et al. Dynamic orthopedic brace in thetreatment of ankle sprains. Foot Ankle Int. 16(7):422-426, 1995.
13. Riddle, D. L., M. Pulisic, P. Pidcoe, et.al. Risk factors for plantar fasciitis: amatched case-control study. J. Bone Joint Surg. Am. 85(5):872-877, 2003.
14. Rodineau, J., and C. Bernasconi. Recommandations sur la prise en charge et letraitement des entorses récentes de la cheville, J. Traumatol. Sport 20:47-54,
2003.
15. Rompe, J. D., J. Decking, C. Schoellner, et al. Shock wave application forchronic plantar fasciitis in running athletes: a prospective, randomized,
placebo-controlled trial. Am. J. Sports Med. 31(2):268-275, 2003.
16. Safran, M. R., J. E. Zachazewski, R. S. Benedetti et al. Lateral ankle sprains:a comprehensive review. Part 2: treatment and rehabilitation with an emphasison the athlete. Med. Sci. Sports Exerc. 31(7 Suppl):S438-S447, 1999.
17. Sandor R., and S. Brone. Rehabilitating ankle sprains. Physician andSportsmed. 30 (8), 2002. On website www.physsportsmed.com, accessed on
10 August 2005.
18. Stephens, M. M., and G. J. Sammarco. The stabilizing role of the lateral
ligament complex around the ankle and subtalar joints. Foot Ankle 13(3):130136, 1992.
Figures 10-1 and 10-2, and Table 10-1 reproduced, with permission, from
Hockenbury R.T., and G. J. Sammarco. Evaluation and treatment of ankle sprains.
Phys. and Sportsmed. 29(2):57-64, 2001. © 2005 The McGraw Hill Companies.

PART 2LOWER EXTREMITY INJURIES
Lower extremity injuries are the most common in athletics. Running, jumping
and throwing produce tremendous ground reactive forces that must be absorbed by
the body’s kinetic chain. Although the foot and ankle are the ﬁrst links in the system,
the forces are transmitted upward.
Normally, muscles absorb approximately 80% of the impact of running, withthe remainder of impact forces taken up by bone and adjacent tissues. The repetitive
nature of running creates multiple musculoskeletal injuries and dysfunction. Muscles
respond in characteristic patterns, which often result in muscle imbalance leading toinjuries.
A. Proximal Extremity Disorders

1. Iliopsoas Strain and Hip Dysfunction
Runners typically spend more time in hip ﬂexion (iliopsoas) and little of therunning stride in hip extension (gluteus maximus). The iliopsoas becomes facilitated,
hypertonic, and shortened. The antagonist muscle, the gluteus maximus, respondswith inhibition, hypotonicity, and weakness. This can alter the arthrokinetics of thelumbopelvic region and lower extremities.
2. Hernias
Different types of hernias may occur, including inguinal, abdominal, or femoral.
Any of these may be caused by a sudden rupture of the fascia and muscle or they
may develop progressively over time. Inguinal hernias are the most common and themost easily diagnosed. Observe for any obvious bulge and palpate over the deep andsuperﬁcial rings for a thrill (Figure 10-6). Occult (sports hernias) are more difﬁcult
to diagnose and often treated as only a “strain.” Early diagnosis is very importantand may require a pelvic CT scan, MRI, or surgical referral. Occasionally, thediagnosis is made via laparoscopy. Surgical repair is the only deﬁnitive treatment.
Abdominal muscles

HerniaFigure 10-6. Inguinal hernia.

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

3. Traction Apophysitis and Avulsion (Figure 10-7)
The rectus femoris takes origin from the anterior inferior iliac spine, and thesartorius takes origin from the anterior superior iliac spine. Both of these muscles
can cause traction at these sites and lead to apophysitis in the young athlete, and also
to avulsion. These should be treated as a 3rd degree strain and managed accordingly.
They seldom, if ever, need surgery.

Hip joint

Pubic bone

Rectus femorismuscleKneecap (patella)

Figure 10-7. Location of a rupture andinﬂammation in the rectus femorismuscle. The injury in this example islocated in the origin of the muscle.

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

4. Hamstring Pain
Hamstring pain is common in athletes and can result from acute tears, chronic
scarring, referred pain from the lumbar spine, or from dural structures.
Hamstring strains are one of the commonest and most disabling injuries tosprinters, jumpers and hurdlers, and accounts for one-third to one-half of the injuries
in this group, and up to three-fourths of the rehabilitation time. Acute strains occur
during rapid acceleration or deceleration, and present as acute pain and a tearing
sensation in the hamstring area. The tear occurs at the musculo-tendinous junction,and can be mild or severe, depending on the number of ﬁbres torn. The athlete will
have pain on stretching the muscle, local pain that may be high, mid-muscle, or low,
and pain on resisted contraction.
The hamstring muscle group consists of the three muscles: the biceps femoris,
the semi-membranosus, and the semi-tendinosus. The hamstring muscles are
predominantly Type II (fast-twitch) ﬁbres that allow the muscle to respond rapidlyin actions such as sprinting. However, Type II ﬁbres are also more subject to fatigue
with repeated rapid contractions, and hence more likely to sustain an injury.
The hamstring muscle group crosses two joints, the hip and the knee, and is
responsible for four different actions:a. Extension of the hip joint in conjunction with the gluteus muscles
b. Deceleration of knee extension at the end of lower leg forward swing
phase, at approximately 30º short of full extensionc. Stabilise the knee during the stance phase of gaitd. Assist the gastrocnemius in extending the knee during push-off
Predisposing factors to injury include:a. Anatomic-lumbar lordosisb. Lack of ﬂexibilityc. Inadequate warm-up
d. Inadequate strength and strength imbalances, esp. quadriceps vs. hamstringe. Muscle fatigue
f. Inadequate recovery and rehabilitation post-injury. (“The commonest causeof an injury is a previous injury.”)
Prevention strategies include:a. Postural evaluationb. Flexibility evaluationc. Strength testingd. Corrective measures for the above
e. Proper warm-up and stretching. Keep muscles warm during activity.
f. Proper conditioning and strength-endurance development
Treatment is through initial PRICES therapy, then good physiotherapy withmassage, ultrasound, a good stretching programme, muscle strengthening, andCHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

graduated return to full activity. Mild tears usually require about 3 weeks forrecovery, but severe tears may delay return to full activity indeﬁnitely.
Chronic scarring may result from repeated hamstring tears, and can cause painin the hamstring with running due to entrapment of nerve tissue in the scarred area.
An aggressive stretching programme and local deep massage are needed to break
down the scar tissue.
High hamstring tendinopathy is a special condition that occurs as an over-use
injury among middle and long-distance runners. Patients note a deep aching pain in
the buttocks or posterior thigh with high-intensity running. This tendinopathy occurs
at the attachment of the hamstrings to the ischial tuberosity. There is ﬁbrosis andhyaline degeneration of the attachment. The ﬁbrosis may entrap part of the sciatic
nerve, leading to radicular neuropathic pain in the extremity, and mimic pain of
lumbo-sacral origin,
Diagnosis may be difﬁcult, although there is usually tenderness at the hamstring
attachment at the ischial tuberosity. An MRI may be needed to demonstrate oedemain the ischium or the tendinous attachment. Treatment involves physical therapy
modalities and a stretching and strengthening programme.
Referred pain from the lumbar spine can cause hamstring pain, and can be related
to facet joint injury or dysfunction, as well as to spondylolysis, spondylolisthesis,
spinal or foraminal stenosis, or disc herniation. Always remember to check the
lumbar spine when someone presents with hamstring pain. Treatment of the lumbar
spine with manual therapy sometimes relieves the hamstring pain.
Dural adhesion between the nerve roots of the lumbar spine and the dura cancause hamstring pain, and can be due to chronic inﬂammation around the lumbar
facet joints or the associated soft tissue. Tightness of the piriformis muscle can also
cause hamstring pain by irritating the sciatic nerve as it passes beside this muscle
or through it. Stretches (including “slump stretches”) have been devised to free theadhered dura and help relieve pain.
5. Adductor Strains
Adductor strains are common in hurdlers and most ﬁeld event disciplines. The
adductor muscles can be strained at their origin at the pubic symphysis or further
distally in the muscle belly. Other conditions may lead to groin pain, and adductor
strains should be differentiated from osteitis pubis, pelvic, or high femoral stressfractures, or sacroiliac joint referral. Adductor muscle strains are tender when
palpated at the area of the strain, and cause pain both on stretching and on resisted
adduction. They can be treated by PRICES and local physiotherapy as mentioned
above. A good stretching programme and appropriate warm up and warm down will
help prevent adductor tears.
6. Referred Pain
Referred pain from the lumbar spine should be managed as appropriate for thesigns found on examination.

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

7. Stress Fractures
It is important to accurately diagnose stress fractures around the hip—if they are
missed they can cause permanent hip disability.
a. Femoral Neck
Stress fractures of the neck of the femur need immediate non-weightbearing (NWB) rest, either in bed or on crutches, depending on whether thereis evidence of fracture on plain X-ray. If the fracture is evident on plain X-ray,then referral to an orthopedic surgeon should be considered for pinning of theneck of the femur to avoid complete fracture and avascular necrosis of thefemoral head. If the cortical defect is on the traction side, surgery is most likely
required, however those on the compression side often heal with rest.
If the fracture is diagnosed only on scintigraphy or MRI, management
should consist of NWB for at least 3 weeks, then only day-to-day activity,
without training, for several weeks. Alternative non-weight bearing training,such as water-running, cycling, and a stretching programme can be followed.
After the end of 12 weeks the athlete may be able to make a graduated returnto full activity.
b. Femoral Shaft
Stress fractures of the upper femur do not put the head of the femur at risk
and a more symptomatic programme can be followed. Usually 8 weeks is
sufﬁcient relative rest using alternative exercise as listed above, followed
by a graduated return to full activity.
c. Pubic Rami
Six weeks is often long enough for pubic rami stress fractures to heal, andbasic rehabilitation principles should be followed.
B. Lower Leg Disorders

Exercise-related leg pain in runners accounts for 10–15% of running injuries,
and may be responsible for up to 60% of leg pain syndromes. The most common
causes of leg pain include:
1. Periostitis (“shin splints,” medial tibial stress syndrome [MTSS])
2. Exertional compartment syndrome
4. Posterior leg disorders: gastrocnemius-soleus strain; achilles tendon
syndromes
3. Stress or fatigue fractures
Shin pain in athletes is difﬁcult to diagnose, and the history of pain plays animportant part in elucidating these problems.
1. Periostitis
Periostitis is the most common shin injury that runners experience. There isonset of pain early during activity, which may subside with continued activity,
although this is variable. Pain may continue following activity. The pain is diffuse

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

along the anterior, but more likely, the posterior border of the tibia. It may be
distinguished from a stress fracture of the tibia by its diffuse nature, as opposed to
the localised pain that occurs with a stress fracture.
The major causes of periostitis are biomechanical problems (usually excessive
pronation), training errors, inappropriate footwear, or major changes in runningsurface or terrain. Biomechanical factors need to be corrected, and proper shoes andappropriate orthoses obtained before therapy can be effective. Local massage ofthe tender areas, combined with ice massage and ultrasound, is the most effective
treatment. Rehabilitation should include relative rest during treatment and a
graduated return to exercise.
2. Exertional Compartment Syndrome
Exertional compartment syndrome is another cause of calf or shin pain. Thiscondition, in which the sheath around the anterior or posterior compartments is tootight, presents with increasing pain with the onset of running. Pain is not present
initially, but over 15–20 minutes the calf or anterior shin pain increases. Pain
comes on earlier if the running pace is harder or if the athlete runs hills. The athlete
experiences a cramping pain, and cannot usually “run through” it. Diagnosis is byhistory and by measurement of compartment pressures in the exercising muscles.
Surgery is usually required to correct the syndrome. The pain will also subside if thelevel of training is reduced, but this approach is not appropriate for an elite athlete.
3. Posterior Leg Disorders
a. Gastrocnemius/Soleus Complex
Calf pain can be caused by small or large tears of the gastrocnemius/soleus
complex. The medial head of the gastrocnemius is a common area to injure,
as is the junction of the Achilles tendon with the calf complex. This can betreated with local physiotherapy and an appropriate stretching regime.
b. Achilles Tendon
Achilles tendinosis is a common problem in athletes. Causes often include
training errors or biomechanical factors, but the condition can come on for
no apparent reason. There can be inﬂammation of the paratenon around thetendon with associated thickening (diffuse), crepitus and pain on movement,or on getting out of bed in the morning. The achilles tendon itself can beinﬂamed with a great deal of local pain on palpation of the tendon. Localised
thickening of the tendon can occur, and is often associated with cystic changes
in the tendon.
Treatment should include the following: correct poor biomechanics, institutea stretching programme, massage the tendon (as well as other modalities), andoversee a graduated return to full activity. Surgery to strip the tendon sheath,remove the cystic area within the tendon, or repair a partial tendon rupture may
be required.

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

4. Stress Fractures—Tibia
Stress fractures of the tibia, ankle, and foot are a major cause of injury (see Part
1 of this chapter, Ankle and Foot Injuries, for further discussion of stress fractures).
Bone is being remodeled constantly. Excessive stresses increase bone turnover, but
repetitive stresses outstrip the bone’s reparative capacity and stress fractures occur.
Precipitating factors include rapid increases in training load, poor or worn footgear,
training on hard surfaces, and failure to heed the symptoms of an impending
fracture. Additional risk factors include low body weight, eating disorders, including
the Female Athlete Triad (disordered eating, amenorrhea, and osteopenia), and otherpoor nutritional practices.
Stress fractures of the tibia are usually located proximally at the tibial ﬂare,and the junctions of the upper and middle thirds, or the middle and lower thirds.
Clinical assessment is usually by local palpation and percussion of the injured siteand by stressing the tibia by a valgus maneuver or by getting the athlete to jump on
the injured leg. These fractures are sometimes seen on plain X-ray, especially if the
X-ray is taken after about 2 to 3 weeks post-onset of pain. However, at best there isa 60% discovery rate. Scintigraphy or MRI is the investigation of choice and should
always be ordered if there is clinical suspicion but a negative X-ray.
Tibial stress fractures require relative rest and alternative non-weight bearing
exercise such as previously described. They typically take between six and eightweeks to heal, and the physician or physiotherapist should work with the coach toplan the athlete’s gradual reintroduction to training. Stress fractures of the anterior
mid-shaft of the tibia are renowned for delayed union and should be treated very
conservatively with rest. They sometimes require bone stimulation and occasionally,bone grafting or drilling.
References

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3.
4.
5.
6.
7.

Alfredson H., and R. Lorentzon. Chronic achilles tendinosis: recommendations
for treatment and prevention. Sports Med. 29(2):135-146, 2000.
Amendola A., and D. Bell. Stress fractures and exertional compartment
syndrome. In Handbook of Sports Injuries, C. R. Bull (ed), pp. 245-263.
New York: McGraw-Hill, 1999.
Athens Marathon. www.athensmarathon.com/marathon/index.html.
Homepage of Athens Marathon, accessed May 2003.
Brukner, P., and K. Khan. Clinical Sports Medicine, pp. 135-146. New York:
McGraw-Hill, 1995.
Clement, D. B. Tibial stress syndrome in athletes. J Sports Med 2:81-85, 1974.
Detmer, D. E. Chronic shin splints: classiﬁcation and management of medial
tibial stress syndrome. Sports Med. 3(6):436-446, 1986.
Fredericson, M., W. Moore, M. Guillet, and C. Beaulieu. High hamstring
tendinopathy in runners. Phys. and Sportsmed. 35(5):32-43, 2005.

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

8.
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Kujala, U. M., S. Orava, and M. Jarvinen. Hamstring injuries: current trends
in treatment and prevention. Sports Med. 23(6):397-404, 1997.
Matheson, G. O., D. B. Clement, D. C. McKenzie, et al. Stress fractures inathletes: a study of 320 cases. Am. J Sports Med. 15(1):46-58, 1987.
Mubarak, S. T., Y. F. Gould, F. Lee, et al. The medial tibial stress syndrome(a cause of shin splints). Am. J. Sports Med. 10:201-205, 1982.
Orchard J., J. Marsden, S. Lord, and D. Garlick. Preseason hamstring muscle
weakness associated with hamstring muscle injury in Australian footballers.
Am. J. Sports Med. 25(1):81-85, 1997.
Sheehan, G. Running and Being: The Total Experience. Red Bank, NJ: Second
Wind II, 1978.
Verrall, G. M., J. P. Slavotinek, and P. G. Barnes. The effect of sports speciﬁctraining on reducing the incidence of hamstring injuries in professional
Australian Rules football players. Br. J. Sports Med. 39(3):363-368, 2005.

PART 3KNEE INJURIES
A. External Knee Disorders

1. Iliotibial Band Syndrome
Iliotibial band (ITB) syndrome is an overuse injury that occurs when the iliotibial
band repeatedly rubs over the lateral femoral epicondyle (Figure 10-8). The soft
tissues in that area become swollen and painful; symptoms are aggravated by further
knee motion. Etiology may be due to rapid increases in training, by overtraining, byrunning on a slanted surface such as a roadside or by running downhill. It can beassociated with biomechanical abnormalities such as genu varum, supinated feetand, in some cases, excessive pronation. On palpation there is tenderness over thelateral femoral condyle as the iliotibial band rubs backward and forward over the
condyle through about 30º of knee ﬂexion, as is common in running.
Treatment includes local physiotherapy to the area, stretching exercises for the
ITB, and attention to biomechanics. Sometimes an adventitial bursa forms below the
ITB; this may respond to local injection with corticosteroid. There is rarely any needfor surgical intervention, but there are some operations described that may help if
conservative measures fail.

Iliotibial
tract
Area of tenderness
over the lateralfemoral epicondyle

PatellaInsertion of iliotibial
tract to tibia

Figure 10-8. Iliotibial band syndrome.

2. Patellar Tendinopathy
Jumpers are especially prone to patellar tendinopathies (Figure 10-9). The injury
occurs at the inferior pole of the patella and can be palpated locally with the knee in
extension or at 30˚ of ﬂexion. Associated thickening and crepitus of the tendon andsheath may also occur. Stretching is important in both prevention and therapy, asCHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

quadriceps tightness is an important cause of the injury. In advanced stages, lesions
such as cystic degeneration or partial tear within the tendon can occur. These can beseen on ultrasound or MRI, and often require surgical intervention. However, therecovery from surgery takes a long time, although results are usually satisfactory.

Femur
Medialcollateral
ligament
Tibia

PatellaSite ofpatellartendinopathy

Figure 10-9. Patellar tendinopathy.

3. Patellar Tendon Insertion Inﬂammation
Inﬂammation of the patellar tendon insertion into the tibial tubercle can occur
from overuse, or be one of the adolescent apophysities. In 12- to 16-year-olds,
inﬂammation of the apophysis called Osgood-Schlatter’s disease can occur. It is
secondary to traction of the patellar tendon on the immature growth plate. Treatment
consists of relative rest, stretching, and gradual increase in athletic activity as thepain subsides.
This injury can also be seen in mature athletes, and is an overuse syndrome
similar to proximal patellar tendonitis. Local physiotherapy is required, but surgery
or local injection is rarely, if ever, needed.
4. Retropatellar Pain
Retropatellar pain or “runner’s knee” is the most common knee problem seen
in runners, and is usually caused by training error or poor biomechanics. Pain isoften felt deep within the knee and into the posterior knee. It is often worse withclimbing stairs or running hills, and after standing up from a sitting position with theknee bent for any length of time (“theatre sign”). Excessive foot pronation is often
associated with the condition, and should be looked for and treated.
This condition responds best to treatment regimes described by Australianphysiotherapist Jenny McConnell. They consist of stretching the lateral muscles of
the quadriceps inserting into the knee and strengthening the vastus medialis obliquus(V.M.O.) muscle to help pull the patella medially. Tape is also used to pull thepatella medially or correct rotational abnormalities. Patellar tracking is corrected by

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

using an exercise programme of limited knee ﬂexion (15º–20º of ﬂexion), making
sure that the patella is aligned over the second toe. Appropriate footwear, with orwithout orthoses, can correct excessive pronation and therefore tibial torsion.
Surgery is rarely indicated for retropatellar pain, unless there is an anatomic defector cartilage degeneration.
5. Quadriceps Insertional Pain
Quadriceps insertional pain occurs at the superior border of the patella. It is anacutely tender area, and the athlete usually will point to the painful spot. It should betreated with the usual physiotherapy modalities.
6. Pes Anserinus Bursitis
Pes anserinus bursitis presents as pain over the medial tibial ﬂare, caused byinﬂammation from rubbing of the hamstring tendons over the bursa separating themfrom the medial tibial ﬂare. This condition can be secondary to excessive pronation,
which should be assessed. It will usually respond to local physiotherapy, but may
require corticosteroid injection.
B. Internal Knee Disorders

1. Meniscal Lesions (Figure 10-10)
Meniscal tears are much less common than previously thought, and many areassociated with an unstable knee in which the anterior cruciate ligament is torn.
Meniscal lesions that are associated with a twisting injury are more obvious thaninsidious cleavage tears of the meniscus. Acute injuries usually involve horn tears orbucket handle tears associated with a speciﬁc twisting injury. Horn tears are almost
always posterior and are associated with a mild-moderate effusion in the knee joint.
Cleavage tears are often degenerative in nature, but can be acute. They are horizontaltears as opposed to the posterior horn tears, which are vertical tears.
Pain may be reproduced in meniscal injury by local palpation over the joint line
or by rotational testing of the tibia on the femur. Patients can “duck walk” in theclinic to elicit pain. Both horizontal and vertical tears are besttreated with arthroscopic repair or
excision, but cleavage tears do notrecover from surgery as quickly
as horn tears, as a large area of
exposed raw meniscus remains
after operation.
Figure 10-10. Locations of themedial and lateral menisci.

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

2. Anterior Cruciate Ligament Tears
Acute knee injuries are rare in runners, but not unusual in athletes in the jumping or throwing events. Tears of the anterior cruciate ligament (Figure 10-11) are
the most devastating types of injury, and are best diagnosed initially on history ofrotational deceleration injury or hyperextension. About 70% of athletes who tear an
ACL report feeling or hearing a “pop” in the knee. Swelling may begin immediately
or within a few hours. If the knee is tensely swollen with blood, aspiration understerile conditions will help relieve the athlete’s pain and make examination easier. A
meniscus tear may produce a slower effusion—perhaps noticed the next morning.
The knee should be examined for laxity at 90º, but this is not as sensitive indiagnosing isolated anterior cruciate tears as the Lachman test. This test is performed
with 10º–20º of ﬂexion and feeling for increased anterior draw.
The pivot shift test is used to detect anterior lateral rotary instability. The patientis placed in a supine position and relaxed. The knee is examined in full extension.
The tibia is internally rotated, with one hand grasping the foot and the other hand
applying mild valgus or abduction stress at the level of the joint. Then, with ﬂexion
in the knee at approximately 20º–30º, a jerk is suddenly experienced at the anterior
lateral corner of the proximal tibia. This shift is the anterior lateral subluxation of thelateral tibial condyle. A positive test is indicative of ACL injury.
Most athletes will require ligament reconstruction using either a hamstring tendon
or the patella tendon as a graft after the initial swelling has subsided.
Femur
Anterior
cruciate
ligament
Lateralcollateral
ligament

Medialcollateral
ligament

Meniscus
Tibia
FibulaFigure 10-11. Anterior view of the right knee in ﬂexion, showing the location of theanterior cruciate ligament.

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

Rehabilitation involves regaining the range of motion initially and reducing theﬂuid in the knee. As movement becomes pain-free, the athlete will be able to run ina straight line and cycle. The next aim is to increase proprioception in the knee; thisis done by balancing on a tilt or wobble board. Retraining the hamstrings is paramount in rehabilitation, as they can compensate for the disability since they attach
to the upper tibia. A planned resistance training programme is needed, primarily tostrengthen the hamstrings but also, to a lesser extent, the quadriceps. Along with
this, the athlete should be taught “catch kicks” to train the hamstring to contract
quickly.
3. Posterior Cruciate Injuries
These injuries occur when the athlete falls directly onto the knee or hyperextends it, and are usually managed conservatively using basic strength
rehabilitation principles. There are problems with retropatellar pain following thisinjury, and quadriceps strengthening is important. Be aware of associated fracturesof the tibial plateau and refer these for orthopedic management.
References

1.

2.

Fredericson, M., C. L. Cookingham, A. M. Chaudhar, et al. Hip abductor
weakness in distance runners with iliotibial band syndrome. Clin. J. Sport
Med. 10:169-175, 2000.
McConnell, J. The management of chondromalacia patellae. A long termsolution. Australian J. of Physiotherapy 32:215-223, 1986.

PART 4SPINAL INJURIES
A. Causes of Spinal Injuries

Track and ﬁeld training and competition create many chances for extreme andpossibly injurious spinal stresses. Postural stress can cause general and speciﬁc
aches and pains, and through accommodation of joint and soft tissue structures,
result in dysfunction. Lifting in weight training, throwing weighted implements,and spinal torsion and compression caused by pole vaulting, jumping, hurdling, andrunning can all cause acute or chronic back syndromes. Precipitating factors include:
1. Sitting Posture
A good sitting posture maintains the spinal curves normally present in erect
standing posture. Poor sitting posture reduces or accentuates the normal curves
enough to stress the ligamentous structures and induce pain. A poor sitting posture
can produce pain to the back itself without any additional stress or injury. An athlete
suffering from low back pain can experience increased pain from sitting or risingfrom sitting. When an individual sits in a chair for a few minutes, the lumbar spine
assumes the fully ﬂexed position, in which the muscles are relaxed and the weightbearing stress is absorbed by the ligamentous structures. An increase in intradiscalpressure occurs as the spine moves toward the ﬂexed position in sitting, and decreases
as the spine moves into extension.
2. Lack of Postural Extension
Another predisposing factor to low back pain is the loss of lumbar extension. A
loss of spinal extension inﬂuences the athlete’s posture in sitting, standing, walking,and running. From faulty postural loading, the spine undergoes adaptive changes.
3. Frequency of Flexed Position
The majority of activities that an individual performs occur in the ﬂexed position.
Theoretically, this produces stress on the annular wall and causes the ﬂuid nucleus tomove posteriorly.
4. Unexpected and Unguarded Movements
Unexpected and unguarded movements in track and ﬁeld may cause an acuteepisode of low back pain. Throwers and jumpers often experience muscular strains
or ligamentous sprains. In attempts to reduce low back pain episodes, it is necessary
to examine and advise each athlete regarding the precipitating factors involved.
5. Lifting
Lumbar intradiscal pressure has been shown to increase with lifting movementsfrom a forward bent position. Maintaining a functional neutral position (an individual’sfunctional range between ﬂexion and extension) and lifting with bent knees aids insymptom-free lifting. Correct lifting and throwing techniques are vital in preventing
back injuries.

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

B. Evaluating Back Injuries

Assessment of back pain should involve a thorough history and evaluation. One
should understand the athlete’s subjective complaints and comments, and determine
the area of symptoms, as well as the severity and nature of the symptoms. The
evaluator should also determine whether the symptoms are constant or intermittent,
and what positions or movements provoke the pain. Objective evaluation of
movement testing to reproduce the symptoms, as well as a neurologic evaluation (ifindicated) should be performed. Back pain of mechanical origin can be classiﬁed as
one of three syndromes:
1. Postural Syndrome
Pain of postural origin is intermittent and appears when soft tissues surrounding
the lumbar joints are placed under prolonged stress. Upon evaluation, inspection
and lumbar range of motion is normal. Postural assessment generally indicates poor
sitting and standing posture; treatment should work to correct posture, strengthen
muscles if any weakness is found, and stretch tight structures.
2. Dysfunction Syndrome
Dysfunction syndrome occurs when adaptive shortening and resultant loss ofmobility cause pain before gaining a full range of motion. Adaptive shortening andloss of mobility can result from poor postural mechanics, spondylosis, trauma, ordisc derangement. Treatment should emphasise lengthening of the shortened tissues
and improving range of motion.
3. Derangement
Disturbance of the intervertebral disc mechanism is responsible for the mostdisabling cause of mechanical low back pain. The actions of the disc have been
described and documented by various authorities to explain the relationship of thedisc and increased pain upon movements. Minor disc bulging may cause deformity
and limitation of movement, and certain movements of the spinal column increase
the bulge while others may reduce it. Shifting the ﬂuid nucleus of the disc may
also disturb annular material. A herniated nucleus pulposus may cause nerve root
compression, radicular symptoms, and altered neurological ﬁndings.
C. Treatment and Rehabilitation

After the potential stresses and the structures are identiﬁed, a plan oftreatment may include back education with a review of proper back mechanics, andassessment of any faulty mechanics present while executing the athlete’s speciﬁcskill; modality intervention; and mobilisation and exercises to achieve pain relief
and regain function. A plan of back care may be a progression of self treatment andmanagement for each individual, depending on the spinal injury.

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

The primary treatment aim is restoration of normal painless joint range by:
1. relief of pain and reduction of muscle spasm
2. restoration of normal tissue-ﬂuid exchange, soft tissue extensibility,and normal joint relationship and mobility
3. correction of muscle weakness or imbalance
4. restoration of adequate control of movement and stabilisation
5. relief from chronic postural stress
6. functional return for the athlete
7. prevention principles to avoid recurrence
8. restoration of the athlete’s conﬁdence
The order of importance for goals will differ with each individual. The
philosophy of treatment and rehabilitation of speciﬁc back injuries may differ
depending on the health care deliverer’s educational and clinical background andexperiences, as well as the treatment and rehabilitation techniques which have
proven successful for that individual. Self treatment should emphasise the principles
of postural correction, repeated extension or ﬂexion movements, use of lumbar aidsand supports, and use of various local treatment modalities such as cryotherapy,
or heat application. Other treatment may utilise electrical stimulation, traction,
acupressure/acupuncture, medical intervention of local injection or oral analgesic/or
anti-inﬂammatory drugs, techniques of joint mobilisation and manipulation, muscle
energy techniques for regaining muscle balance, PNF (proprioceptive neuromuscularfacilitation), mobilisation techniques for soft tissue and nerves (see Chapter 8, Part
3, Principles of Rehabilitation of the Injured Athlete, for more detail). Functional
lumbar stabilisation progression and functional training may be integrated as one
or in combination depending on the athlete’s deﬁcits and the goals of treatment andrehabilitation.
The lumbar spine has optimal positions in which it functions most efﬁciently
and these positions vary depending on the stresses it must withstand. There is no one
best position for all functional tasks and activities, and it will vary from athlete toathlete. A good functional position is generally near the mid-range of all available
movement of the lumbar spine, and the athlete must learn good lumbopelvic control.
For the athlete to learn to maintain the low back within a functional range, he or
she must develop a kinesthetic sense in order to feel and control back movements
and positions so that it becomes a habit during all activities, and the athlete must
maintain this coordination, strength, mobility, and endurance to perform well.
Management in preventing recurrences of back injury for the track and ﬁeld
athlete begins with an understanding of what they do, how they do it, and thecause of injury. The basic principle is to avoid extreme positions or extreme
stress for long periods, and continue with preventative/maintenance exercises forrange of motion, muscle ﬂexibility, strength, and power.

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

References
1. Grieve, G. Common Vertebral Joint Problems, 2nd ed. New York: Churchill
Livingstone, p. 521-566, 1988.
2. Maitland, G. Vertebral Manipulation. Boston: Butlerworths, 1988.
3. McKenzie, R.A. The Lumbar Spine: Mechanical Diagnosis and Therapy.
Course syllabus, 1990.
4. Morgan, D. Training the Patient with Low Back Dysfunction. Course syllabus,
pp. 11-13, 1990.

PART 5

UPPER EXTREMITY INJURIES
Upper extremity injuries usually occur in the shoulder or elbow of javelin, discus,or hammer throwers or shot putters. Overuse (too much too soon), biomechanicalimbalance due to improper technique, or failure to completely rehabilitate a priorinjury are the most common causes. Runners may injure an upper extremity due to afall, collision, or other accident. More injuries occur in training than in competition.
The entire body is important in maximising optimal performance and inpreventing injuries of the upper extremity. Hip-shoulder orientation and trunk
position change throughout the throw. A shot putter must support the heavy shotwith his or her ﬁngers while the large scapular anchoring muscles must slow the arm
after the shot has been released. Discus and hammer throws are centrifugal motions
that produce fewer shoulder problems than do overhead events.
A. Shoulder Injuries

Throwing actions place a signiﬁcant demand on the shoulder complex, requiring
a precise, coordinated effort to create velocity and accuracy. The most common
injuries in throwers include rotator cuff tendinitis due to overuse and eccentric
overload, subtle instabilities, labral degenerative changes and tears, and secondary
subacromial and parascapular pathology.
1. Rotator Cuff Tendinopathy and Impingement Syndrome
Rotator cuff tendinopathy is the most common cause of shoulder pain inthrowers. The rotator cuff muscles are the supraspinatus, infraspinatus, teres minorand subscapularis (Figure 10-12). Also making up the functional unit of the rotator
cuff are the long head of the biceps brachii tendon, the acromion process, thecoracoacromial ligament, and the acromioclavicular joint.

Supraspinatus
Deltoid
Infraspinatus

Teres minor

GlenoidlabrumSubscapularis

Posterior View

Anterior View
Figure 10-12. Rotator cuff muscles and insertions.

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

The rotator cuff’s three primary functions are humeral head depression, active
external rotation of the shoulder, and dynamic stability of the shoulder. The rotator
cuff maintains the articulation of the humeral head within the glenoid, thereby
supplying an effective fulcrum across which the power muscles of the shoulder(deltoid, pectoralis major, and latissimus dorsi) act to elevate the arm and permit
active use at and above the shoulder level (Figure 10-13). The posterior rotator cuff
muscles, the infraspinatus and teres minor, are the principal external rotators of
the shoulder. The surface of the humeral head is three or four times larger than the
glenoid. The rotator cuff muscles provide dynamic stability of the glenohumeral
joint while the glenohumeral ligaments provide static stability.

Trapezius

Deltoid
Pectoralis
major

BicepsFigure 10-13. Major shoulder muscles.

Rotator cuff tendinitis can occur in several ways. If the glenohumeral joint
static stabilisers fail to contain the humeral head, the rotator cuff must substituteby eccentrically contracting. Increased muscle load leads to early fatigue, eccentric
overload, and inﬂammation. The supraspinatus muscle and tendon play the largest
role in head depression during shoulder abduction and therefore are the site of
most common overuse injuries. When fatigued, the shoulder no longer resists
superior head translation, leading to impingement in the subacromial space. The
infraspinatus, teres minor and posterior deltoid externally rotate the shoulder,
while the pectoralis major and latissimus dorsi assist the subscapularis withinternal rotation. Inequality in strength of internal and external rotation may leadto tendinitis. Weakness of the external rotators while the shoulder is deceleratingin the follow-through may lead to fatigue and then tissue damage, especially of theinfraspinatus tendon.

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

Impingement syndrome is a symptom complex initially described and classiﬁed
by Neer (1972). The primary symptom is anterior shoulder pain which sometimes
radiates laterally to the deltoid insertion and is exacerbated by activities at shoulder
level or above (Figure 10-14). The functional arc of elevation of the shoulder is in
the frontal, not lateral plane. Mechanical impingement of the rotator cuff against
the anterior aspect of the acromion and the coracoacromial ligament may leadto inﬂammation and subsequent tears of the rotator cuff tendons. Neer classiﬁed
three stages of the impingement syndrome as: 1) oedema and hemorrhage in thesubacromial space; 2) thickening and ﬁbrosis of the subacromial bursa; and 3)
full thickness rotator cuff tears. Instability of the glenohumeral joint may lead to
impingement due to abnormal anterior humeral head translation secondary to thelaxity.
When the arm is lifted upward andoutward (abduction) at an angle of
70º–80º to the body, the bursa and the
injured tendon may be trapped against
the lower edge of the shoulder blade andagainst the coraco-acromial ligament,
causing pain. The condition is called
trapping or impingement syndrome.

When the arm is further lifted upward
and outward at an angle greater than120º, the bursa and the injured tendon
slide under the acromion process of theshoulder blade. This releases the pressure,and therefore the pain, on the tendon.

Figure 10-14. Impingement syndrome.

Examination of a patient with shoulder impingement usually reveals a painfularc from 80º to 140º abduction in forward ﬂexion. Common impingement tests are:1) forced passive stretching and extreme forward ﬂexion of the shoulder with theforearm pronated; 2) forced internal rotation at 90º of forward ﬂexion; 3) extreme
horizontal adduction (cross-over test). Injecting the subacromial bursa with Lidocaine should signiﬁcantly decrease or eliminate the pain with the impingement test.

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

2. Shoulder Instability
Shoulder instability is deﬁned as excessive symptomatic displacement of thehumeral head in its relationship to the glenoid fossa. Subluxation is the partial lossof joint congruency. Instability may result from acute trauma or chronic repetitive
stresses, which slowly elongate capsular restraints. Acute dislocations are usually
the result of a fall, while throwers may acquire shoulder instability over a period oftime.
An athlete with a current dislocation frequently presents holding his or her arm
by the opposite hand in slight adduction and external rotation. The acromion may
be prominent and there is a sharp contour of the affected shoulder compared to thesmooth deltoid outline of the uninjured shoulder. The shoulder should be reduced
and immobilised.
When the instability is due to chronic repetitive stresses, the history will be lessobvious. The symptoms may often be vague and the diagnosis difﬁcult to make. The
pain is sometimes poorly deﬁned but may be worse with horizontal adduction andexternal rotation. There may be a vague feeling of instability or apprehension withoverhead movement.
Examination of the patient with subtle shoulder instability may reveal that therange of motion is grossly equal in both shoulders. Most likely there will be someapprehension with the shoulder in 90º of abduction and maximal external rotation.
The “relocation test” described by Jobe and Kvitne (1990) may be positive. Thisis performed with the patient lying supine and the shoulder abducted 90º andmaximally externally rotated. Anteriorly directed forces on the proximal humerus
should cause pain and a sensation of anterior subluxation which is relieved byposterior pressure on the anterior aspect of the humerus. Testing for posterior
instability can be done with the arm at shoulder level and adducted approximately
30º while applying posterior-directed force to the humeral head. X-rays may reveal
a Hill-Sach’s lesion, which is a defect of the humeral head due to compression of
the head against the glenoid while the humerus subluxes. A CT/arthrogram may beneeded to rule out a rotator cuff tear. Complex multi-dimensional instabilities may
be difﬁcult to diagnose.
3. Stress Fracture
A stress fracture of the proximal humeral physis or osteochondritis is common
in the athlete with an immature skeleton. Repetitive stress caused by torque during
the acceleration phase of throwing while the arm accelerates forward and rotatesinternally may lead to tendinitis in adults and stress fractures in youths. The
strong young athlete’s shoulder ﬂexors, internal rotators, and adductors can exert
tremendous force on the proximal humeral physis.
Young athletes with stress fractures usually present with pain produced bythrowing. There may be focal pain over the deltoid insertion and perhaps the generalrotator cuff without any instability or impingement signs. The pathognomonic
radiographic ﬁnding is widening of the proximal humeral physis compared to thenormal shoulder.

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

Treatment should consist of possibly limited immobilisation, ice, and physicaltherapy, with a strength programme beginning at 4 weeks and perhaps return tothrowing in 8 weeks.
B. Evaluation Guidelines

1. Differential Diagnosis
It is important, although sometimes difﬁcult, to make a deﬁnitive diagnosis
when a shoulder injury occurs. History and examination of shoulder injuries should
rule out other pathology as a referred source of shoulder pain. Cervical injuries,
including degenerative joint disease and radiculopathies, may refer pain into
the upper extremities. Pain may also be referred from the thoracic spine and theviscera. Other possible causes are thoracic outlet syndrome, brachial plexus injury,
subclavian artery occlusion and peripheral nerve entrapment, or myofascial pain
syndrome.
2. Examination
The shoulder examination should begin with observation of both shoulders
relaxed and contracted. Any asymmetry, muscular atrophy, effusions, erythema,ecchymosis, winging of the scapula or lateral glide or obvious dislocation or
separation should be noted. Any crepitus or popping during the examination
should be noted. A screening examination of the cervical and thoracic spine shouldbe performed and a more detailed examination of these areas done if history or
examination warrants.
Range of motion testing should include active, passive, resistive, and functional.
The examination should include the impingement instability test.
Imaging, which may be indicated, may include x-ray, CT/arthrogram, magnetic
resonance or bone scan.
3. Treatment
Treatment should be diagnosis speciﬁc but may include relative rest,
immobilisation, physical therapy, ice, anti-inﬂammatory medication, spontaneous
reduction, surgery, and correction of biomechanical imbalances.
C. Elbow Injuries

1. Valgus Overload Syndrome
Valgus overload syndrome is one of the most frequent and signiﬁcant elbow
injuries in javelin throwers. This syndrome is caused by a combination of medial
tension overload and lateral compression overload. The javelin should be thrownoverhead with elbow extension; incorrect “round arm” throws lead to valgus
overload.
a. Medial Tension Overload
A great deal of force is exerted on the ﬂexor and pronator attachments at
the medial epicondyle when the arm is abducted and externally rotated in theCHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

throwing motion. Repetitive traction stress results in micro-tearing of thetendon or of the muscle ﬁbres near the epicondyle. The bony attachment isstronger than the tendon or muscle ﬁbres, and an ulnar traction spur with focal
calciﬁcation in the tendon substance may develop. In an immature athlete,
repetitive stress may cause separation of the epiphysis.
b. Lateral Compression Syndrome
Strong compressive forces to the lateral joint of the elbow associated with
valgus stress may lead to damage of the radial head, capitellum, or both(osteochondral fracture and even loose body may result). Symptoms include
lateral elbow pain with activity, and catching or locking. Signs would include
a tender radiocapitellar joint, lateral swelling, or crepitus with forearm
pronation-supination. X-rays may reveal a loss of the radiocapitellar joint spacewith marginal osteophytes or loose bodies. If symptoms are not resolved withrest and anti-inﬂammatory medication, treatment may include joint debridement with removal of marginal osteophytes and loose bodies.
2. Ulnar Nerve Damage
Chronic over-stress at the medial elbow can cause ulnar nerve damage due tochronic inﬂammation or chronic stretching. The ulnar nerve may become inelastic or
mobile and be compromised due to formation of ﬁbrous scar tissue.
3. Joint Degeneration
The articulator surfaces of the radius and capitellum are subjected tocompressive and rotational loading. Throwers can develop loose bodies in thelateral compartment, as well as osteocartilaginous fragments or marginal spurs.
Osteochondritis dissecans of the capitellum may occur in the immature athlete.
Extension overload can strain the triceps at the musculotendinous junction. The
combined effects of excessive medial traction, lateral compression, and extension
overload can result in excessive joint degeneration.
4. Bicipital Tendinitis and Rupture
Another frequent elbow overuse syndrome is bicipital tendinitis due to excessive
elbow ﬂexion and supination. Symptoms include anterior elbow pain with ﬂexion
and supination, and weakness secondary to pain. One must rule out a partial orcomplete biceps tendon rupture, a brachialis muscle tear, an anterior capsule tear, or
lateral antebrachial cutaneous nerve compression syndrome. Approximately 97% of
biceps tendon ruptures occur at the proximal aspect; only 3% occur distally. Male
athletes over 30 years of age who have been treated with corticosteroid injections
are most likely to sustain a bicipital tendon rupture.
5. Median Nerve Compression Syndrome
Median nerve compression syndrome (pronator syndrome) may occur due tomechanical compression by hypertrophied muscle or aponeurotic fascia. This may
initially be misdiagnosed as lateral epicondylitis, because there is signiﬁcant lateral

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

supracondylar pain with pain in the anterior proximal forearm. Cramping may occur.
There may be numbness in the volar forearm or radial 3 1/2 digits and thumb. There
should be a positive Tinel’s sign at the proximal forearm, but negative Tinel’s signat the wrist and a negative Phalen’s sign at the wrist. Resisted palmar ﬂexion of the
middle ﬁnger may produce pain at the medial elbow rather than the lateral. Surgicaldecompression may be necessary if rest, modiﬁed training, and physical therapy do
not resolve it.
6. Triceps Tendinitis and Fracture
Posterior elbow pain may be a sign of triceps tendinitis due to overload of
the triceps by repetitive extension. X-rays may be normal but may demonstratedegenerative calciﬁcation, hypertrophy of the ulna, or triceps traction spur.
Differential diagnosis should include bursitis or a stress fracture of the olecranon. A
triceps fracture may occur with or without olecranon avulsion.
7. Lateral Epicondylitis
Throwers often experience lateral epicondylitis due to overload of throwing or
weight training. The athlete will have pain over the lateral epicondyle, and frequently
over the radial head and extensor tendons of the forearm. Resisted dorsiﬂexion of
the wrist should increase the pain.
D. Wrist Injuries

1. Tendinitis
Tendinitis of the wrist and ﬁngers occurs in athletes who must repetitively ﬂexand extend their wrist. Tenosynovitis and ganglion cyst may occur. Overuse injuriesof the ﬁngers are relatively rare but may occur.
2. Wrist Fracture
A carpal navicular or scaphoid fracture is one of the most frequently missed
fractures in the athlete. Any athlete who has tenderness to palpation of the anatomic
snuff box between the extensor tendons of the thumb just distal to the radius shouldbe treated as if the scaphoid is fractured even if the initial X-rays are negative.
Repeat ﬁlms 10–14 days later may show the fracture line as bone resorption
progresses. Appropriate immobilisation for this fracture is a thumb spica cast.
Surgery may be needed if there is a non-union.
3. Carpal Tunnel Syndrome
Carpal tunnel syndrome may occur due to repeated ﬂexion and extension of thewrist. The median nerve may be entrapped. The athlete may complain of numbness,tingling, and pain, primarily in the thumb and three radial ﬁngers. Retrograde pain
and paresthesia may occur. Tinel’s sign and Phalen’s sign should be positive. (Tinel’ssign is tapping the carpal tunnel to reproduce the tingling sensation. Phalen’ssign is forced volar ﬂexion of the wrist for 90 seconds or more to reproduce thetingling.) Signiﬁcant weakness of the adductor pollicis brevis and opponens pollicis

CHAPTER 10, SPECIFIC INJURIES BY ANATOMIC SITE

muscles may occur. Electromyography and nerve conduction velocity tests may
be needed for positive diagnosis. Treatment should include splinting, nonsteroidal
anti-inﬂammatory medication, and physical therapy. In some cases, surgicaldecompression may be needed.
4. de Quervain’s Syndrome
Stenosing tenosynovitis of the ﬁrst dorsal compartment of the wrist is called deQuervain’s syndrome. There may be pain and swelling of the abductor pollicis andextensor pollicis brevis. Finkelstein’s test is positive. (The patient should tuck hisor her thumb inside the other ﬁngers while the physician moves the ﬁst into ulnar
deviation; a positive test is pain in the tendons where they cross the distal radius.)
Treatment should include rest with a thumb spica splint, physical therapy, followed
in some cases by a corticosteroid injection.
References

1.
2.
3.

4.

5.
6.
7.

Auferoth, Steven J. Power training for the developing thrower. National
Strength and Conditioning Assoc. J. 8(5):56-63, 1986.
Cantu, Micheli. ACSM’s Guidelines for the Team Physician. Philadelphia:
Lea & Febiger, 1991.
Jobe, F. W., and R. S. Kvitne. Shoulder pain in the overhand throwing athlete.
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