Transcript Sports Injuries in the Aging Athlete

Common Problems of
the Aging Athlete
Brian L. Badman M.D.
Orthopedics and Sports Medicine of
Indiana
Hendricks Regional Health
Rotator Cuff Injuries
Rotator Cuff Anatomy
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4 muscles/tendons
Supraspinatus
 Infraspinatus
 Teres Minor
 Subscapularis
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Rotator Cuff Function
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Shoulder rotation
Arm elevation
Helps keep humeral head within shoulder socket
Rotator Cuff Injuries
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The position of injury for the rotator cuff is
overhead
WHY?
Rotator Cuff Injuries
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Overhead Position
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Impingement between humerus and acromion
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Least efficient/weakest position for cuff
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Poor blood supply to tendons
Rotator Cuff Injuries
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What causes the injury?
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Trauma
Fall on an outstretched hand
 Arm forcefully pulled to side or downward
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Overuse
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Repetitive lifting, loading
Traumatic Causes
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Tear of Tendons
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Partial
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Complete
Overuse Causes
Chronic Inflammation
Bursitis
Fraying
Gradual progression of tear
ONCE TEARING STARTS IT IS EASIER TO PROGRESS
Why Does it Worsen?
Weakened cuff cannot protect itself
Space between acromion and humerus narrows
Impingement worsens
Tear progresses
Watershed Region/Zone of Injury
Torn Rotator Cuff
Symptoms
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Pain in deltoid region
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Upper outer arm
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Pain worse with overhead activities
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Night pain
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Pain with exertion
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Lifting
Symptoms
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MUST ALWAYS EVALUATE NECK AS
SYMPTOMS FROM A HERNIATED DISK
CAUSING NERVE IMPINGEMENT ARE
SIMILIAR
Evaluation
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History
Physical Examination
MRI
Evaluation
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History
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Trauma, location, provocation of symptoms
Exam
Pain with isolated cuff testing
 Impingement signs
 Weakness
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Evaluation
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MRI
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NEED HIGH QUALITY MAGNET!
Insurance will pay the same so might as well insist on best
quality study
 Your doctor may not be aware that this is important so
stress the need for a CLOSED MRI unless you are
claustrophobic
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In-office
 Open MRI
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POOR QUALITY STUDIES
Treatment
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If have a partial tear or cuff just inflamed
(bursitis, tendonitis)
Physical Therapy
 NSAIDS (Motrin, alleve, advil, celebrex)
 +/- Steroid Injection
 Rest
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Avoid overhead activities and lifting
It may take several months for pain and
inflammation to resolve
Rotator Cuff Exercises
Rotator Cuff Exercises: High Level
Treatment
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Complete Tear
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In active individuals surgery is generally indicated
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Rotator cuff will not heal itself
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Results are better if a traumatic tear is fixed acutely (2-3
weeks)
Takes 12 weeks for repair to heal to bone
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Anticipate a year to recover
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3 monthsbegin overhead activities
6 monthsMay resume most activities as long as motion is good
Postop Rehab
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Because the cuff heals slowly (12 weeks
minimum) the repair is easily damaged if
stressed too soon after surgery
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Slow progression with motion and strengthening
is necessary
May result in stiffness
 Usually resolves but may take entire year to return
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Goals of Surgery
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Repair tear
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Alleviate pain
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Maintain full ROM
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Maintain strength
Surgery
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Arthroscopic
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Open
Healing times are the
same!
Surgery
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Arthroscopic
Less pain
 Small incisions
 ?Less stiffness
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Some tears are not repairable thru the scope
Some tears are not repairable at all!
Arthroscopic Surgery
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Acromioplasty
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Make more room for repair and eliminate spurs that
may have predisposed to tear
Arthroscopic Surgery
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Place anchors with sutures attached
Knee Injuries:
Diagnosis, Treatment
and Prevention
Anatomy Definitions
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Ligaments: Connect bones around joints,
Provide joint stability Check reins
Tendons: Anchor muscles to bones Cords
Bones: Structural Supportsscaffold
Articular Cartilage: Gliding Cartilage, Low
friction smooth surfaceCovers Bone
Meniscal Cartilage: Cushion Cartilage
Shock absorber
Anatomy
Ligaments
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ACL: Anterior
Cruciate Ligament
PCL: Posterior
Cruciate Ligament
MCL: Medial
Collateral Ligament
LCL: Lateral
Collateral Ligament
Bone
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Provides structural support
Attachment Site for muscles, ligaments tendons
Bursa: Fluid filled sack covering bone, reduces
friction
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Bursitis: Inflammation of the sack due to trauma,
excess friction
Subject to fracture and bruising with trauma
Tendons
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Connect muscle to bone
Glide in confined spaces
Subject to friction
Leads to inflammation
when overused
Trainable, Adapt to use
Articular Cartilage
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Gliding cartilage on joint surface
Specialized low friction, shock
absorbing material
Lubricated by specialized fluid
Arthritis: Wear and
inflammation lead to roughening
of the cartilage surface, less
efficient more friction
Articular Cartilage Injuries
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Can result from chronic wear or sudden injury
Can delaminate at bone-cartilage interface
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Sx:
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Pain
 Swelling
 Popping
 Catching
 Locking
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Knee Arthroscopy
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Small incisions
Camera placed into the
joint
Small instruments trim
and smooth cartilage
Operate using a video
monitor
Surgical Treatment
Treatment
New Treatments
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Autologous
Chondrocyte
Implantation (ACI)
Grow your own
cartilage and reinsert
into the knee
Larger 2 staged surgery
Grows new gliding
cartilage
Prevention
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Difficult
Injury/ Trauma avoidance
Adequate sports preparation, muscle balance
Jumping, landing skills
Don’t ignore joint instability- increases risk of
further injury to the cartilage
Possible role for glucosamine, chondroitin
Result
Meniscal Cartilage
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Located between the
femur and tibia
Acts like a shock
absorber in the knee
Structurally different
from articular cartilage
Subject to tearing and
can “pinch” in joint
Meniscus Injuries
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Tears of the cushion
cartilage in the knee
Sx:
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Popping
Sharp pain along joint
Swelling
Twisting pain
Flexion, squat, stairs
Locking if displaced
Treatment
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Rest, Activity
modification
Strengthening, therapy,
Steroid Injection +/Surgery for continued
sx’s or recurrence
Surgical Appearance
Prevention
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Difficult, often part of the aging process
Meniscus weakens, susceptible to tearing
Stressed more with twisting, deep bending
Routine low impact exercise
Caution with deep flexion exercise
Choose your parents well
Knee Injuries
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Overuse injuries: Tendonitis, Bursitis
Traumatic Injuries: Meniscus tears, Articular
cartilage tears, Ligament tears, (Fractures)
Cumulative Injuries: Arthritis
Overuse Injuries
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Repetitive stress on de-conditioned tissues
All tissues are injured with use and age
Tissues repair themselves during rest periods
Many injured tissues can regenerate with time
Recurrent injuries with incomplete repair can
accumulate resulting in inflammation
Patellar Pathology
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Patellar/ Quad tendonitis
Patellar Chondromalacia
Patellar Instability
Patellar Tendonitis
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Inflammation of a tendon
Poor blood supply, slow to repair
Over training or too rapid
advancement in training
Inadequate stretching
Excess loads can lead to partial
tearing
Tendonitis Treatment
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RICE: Rest, Ice, Compression, Antiinflammatory medications
Stretching, Deep tissue massage
Reduce inflammation then gradual return to
exercise
Low impact, no jumping, Quadriceps
strengthening, Physical Therapy
Tendonitis Prevention
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Maintain good strength and flexibility
Gradual advancement of activity
Early intervention with injury or pain
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Ice, Motrin, Stretch, massage
Reduce stressful activity
Patellar Chondromalacia/Anterior
Knee Pain Syndrome
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Pain in front of knee
Worse with bending,
stairs
Grinding, crunching
under knee cap
Due to roughening of
cartilage, malalignment
Patellar Pain
Treatment
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Reduce Inflammation
Improve muscle balance, therapy, strengthening
Bracing, taping patella
Pain decreases as alignment improves
Surgical options: Smooth cartilage, Realign
patella to track more normally
Surgical Treatment
Prevention
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Improve muscle balance, quadriceps strength
Avoid deep bending exercise (Patella stress
goes way up)
Minimize stair climbing, inclines
Exercise on level surfaces
Avoid leg extension machine
Knee Ligament Injuries
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Strains or tears of the joint check reins
MCL/ACL Tear most common in Knee
Sx’s:
Pain, swelling, decreased range of motion
 Later looseness, instability, giving way episodes
 Problems with cutting, twisting movements
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Too much motion of knee
Both Men and Women at risk
ACL Injuries
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Primary restraint to anterior tibial translation
Essential to pivoting, cutting
Involved in proprioception
Limited capacity to repair after injury
>200K injuries/year
>100K reconstructions/year
Ligament Injuries
Noncontact ACL injuries
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Clear female predominance
2x soccer, 4x basketball FM:M
Multifactorial causes: Decreased muscle
protection, ACL size, narrow notch, menstrual
cycle
Mechanical: Valgus align, land in extension,
less muscle co-contraction add tension to ACL
Jumping, landing training can reduce risk
Treatment
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Initially: Stop play, Ice,
Compression, Crutches
Motion, Leg raises
Exam, Imaging studies
Prehab
Bracing
Surgery
ACL Surgery
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Most common ligament surgery
Replace rather than repair
Arthroscopic surgery
Create new ligament from other tissues:
Patellar tendon, Hamstring tendons
Six months before return to play
ACL Surgery
ACL Surgery
ACL Injury Prevention
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Adequate sports preparation (Skiing)
Good Quad/Hamstring balance, tone
Practice jumping, landing, twisting (Esp Females)
Recognize fatigue and back off
Knee braces don’t prevent injuries
PCL Tears
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Less common than ACL
Contact, tackle sports
Often from fall on flexed knee, blow to
anterior knee, posterior stress
More easily compensated for than ACL
TX: RICE, rehab, brace
Surgery for multi-ligament injury (LCL, lat
complex)
MCL Tears
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Most common knee lig injury
Cutting, twisting, blow to lateral knee, valgus
stress
Medial pain, varying degree of medial laxity
on stress exam
Tx: RICE, brace, motion, rehab, brace
Iliotibial Band Syndrome
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Overuse/ friction bet IT band and Lat epicondyle
Runners, cyclists, repetitive flexion activities
During flexion ITB passes from ant to post to the
lateral femoral epicondyle. Bursa reduces friction
Causes: ITB tightness, varus, foot pronation,
Internal tibial torsion, crossing midline at heel
strike
Clin: Lateral pain, may radiate, downhill, stairs
Tx: Rice, ITB/hip stretch, NSAIDS, act mod,
running technique changes
Knee Arthritis
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Wear of the gliding
articular cartilage (OA)
Roughness increases
gliding friction
Sx:
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Pain, inflammation, swelling
Pain with weather change,
load bearing
Improves with rest, antiinflammatory medicines,
low impact exercise
Arthritis Treatment
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Goal: Reduce pain, swelling, maintain motion,
minimize disability, slow joint destruction
Modalities: Anti-inflammatory meds, steroids,
braces, cane, exercise
Newer: Glucosamine/ Chondroitin tablets,
Lubricating fluid injections (Hyalgan, Synvisc,
Orthovisc, etc.), electromagnetic field currents?
Surgery, Last resort
Knee Replacement
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Remove worn cartilage
surface
Replace with metal and
plastic bearing surface
6 month recovery
10-15 year
longevity90%
Arthritis Prevention
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Minimize trauma
Regular low impact exercise
Disease modifying agents on the horizon
Vitamins/Anti-oxidants
Glucosamine/Chondroitin