Sports Injuries

Rotator Cuff Injuries

Achilles Injuries

Knee Injuries

Rehabilitation

The rotator cuff (supraspinatus, infraspinatus, subscapularis, and teres minor) holds the humeral head tightly in the glenoid fossa of the scapula. Tearing and inflammation of the tendons of these muscles often occur in sports requiring the arm to be moved over the head repeatedly; eg, pitching in baseball; moving the arm forward when swimming the free style, backstroke, and butterfly; lifting a heavy weight over the head in weightlifting; and serving in racket sports. Reaching forward causes the humeral head of the anteriorly flexed shoulder to abut the acromium and carocoacromial ligament, which in turn is rubbed by the tendon of the supraspinatus. Chronic irritation can cause subacromial bursitis, inflammation of the tendons, and tearing of the rotator cuff. If exercise continues in spite of the pain, the lesion progresses to a periostitis and then avulsion of the tendons from their attachments on the humeral tuberosities.

Initially, pain occurs only when the athlete participates in any sport that requires him to hold his arm over his head and forcibly bring it forward. Later, pain may occur when the arm is moved forward to shake hands. Usually, pain will be elicited by pushing things away, with little or no pain on pulling objects in. To palpate the rotator cuff, abduct the arm backward and away from the body in internal rotation with the elbow straight. The patient will complain of tenderness over the tendons, especially when the arm is raised above the shoulder, but often not when the arm is held down by the side. Severe pain is caused by adduction of the arm across the chest. Shoulder abduction will be weak, usually due to underuse atrophy of the deltoid. An arthrogram is usually not sensitive enough to diagnose a partial tear of the rotator cuff but not demonstrate a complete tear.

First, the injured tendons should be rested and the uninjured shoulder muscles strengthened. The patient should avoid exercises that push things away and do ones that bring things towards him, provided there is no pain; eg, upright rows and downward "lat pulls".

Surgery may be necessary if the injury is particularly severe, if there is a complete tear of the rotator cuff, or if the tendons do not heal within 1yr. For more information check out our Shoulder section.

The Achilles tendon has 2 major functions during running. The calf muscles (1) lower the forefoot to the ground after heelstrike; and (2) raise the heel during "toeing off". Achilles tendinitis is caused by a force on the tendon greater than its inherent strength.

Most runners land on their heels with their forefoot still 2 in from the ground. Running fast and up and down hills places extra force on the Achilles tendon. During downhill running, the forefoot strikes the ground with greater force than on level ground, since it drops further and has more distance to accelerate. During uphill running, the heel is much lower than the forefoot, so it takes a much greater force by the calf muscles to raise the heel before toeing off.

A soft heel counter allows excessive movement of the heel in the shoe. The rearfoot is not as stable and the Achilles tendon has to pull on a wobbly insertion. This places unever force on the tendon and increases its chance of being torn. Stiff-soled shoes that do not bend just behind the first metatarsophalangeal joint place great stress on the Achilles tendon just before toeing off.

The tendon can be strained, or suffer a minor tear, at or close to its point of insertion on the heel. Or the bursa between the tendon and the upper part of the bone may become inflamed. The condition may be complicated by small bony outgrowths (spurs) forming on the heel-bone. The spur sometimes becomes detached, formed a focal point of pain.

The pain usually comes on gradually, but it can be sudden. You feel it tiptoeing or running, and the tendon feels tender over the heel when you press on it. The cause is usually excessive use of the calf in extreme ranges of movement, as, for instance, when you run fast up a steep hill. Rough, protruding linings in your shoes can also be a cause, producing bruising and tenderness over the heel.

Specialist treatment may consist of an injection, or physiotherapy treatment. Your doctor may have X-rays taken, to make sure that there is no damage to the heel-bone, or spur formation. It may be necessary to line the backs of your shoes with felt or padding, to create a smooth surface. This injury is slow to heal, so you must rest it.

The tendon may become sore, thickened, and tender to touch at any point up to about five centimetres above the top of the heel-bone. Some of its fibres may be torn or degenerated, while the tendon's covering becomes thickened. The tendon feels stiff first thing in the morning, and on starting exercise. When you stand on your toes barefoot, the tendon hurts at first, but then eases. However, it remains very sore to touch.

The cause is almost invariably friction from shoes with high backs, or heel-tabs. The first priority is to remove the cause: cut down the heel-tabs with two vertical slits on either side of where the tendon lies, to the level of the back of your ankle, usually about five centimetres above the upper edge of the sole. If there is no spasm causing pain higher up where the tendon joins the calf muscle, you can safely resume running and sports provided you warm-up and warm-down thoroughly. The tendon may remain thickened and sore to touch for months, possibly years, but provided you feel no pain during exercise, it is safe for you to continue your sport.

This may happen at any level in the tendon. A sudden severe pain occurs, which often feels like a violent blow to the calf. Swelling and bruising may appear, and the two broken ends of the tendon often leave a visible gap. Usually, you fall at the moment of injury, and walking is then too painful to try.

The cause can be a blow to the muscle or tendon when they are tensed. More often, the injury is caused by strenuous activity involving the calf, such as sprinting or playing squash. The injury may occur at the beginning of the activity, when the muscles are 'cold' and tight.

At the moment of injury, it may not be clear whether the tendon is completely torn. One test for this is to lie on your stomach, and have someone squeeze the calf muscle bulk gently: if the tendon is partly intact the foot will move to point downwards, but if the tear is complete, the foot will remain still.

This injury requires specialist treatment, which may consist of surgery, to stitch the two tendon ends together, or immobilization in a plaster cast, allowing the tendon to heal naturally. After surgery, you can usually resume sport within three to four months. If your leg is immobilized, the plaster will be on for eight to twelve weeks, so, after rehabilitation, you will probably resume sport about six months after the injury.

This can arise from various causes. The knee can be affected by a spontaneous inflammatory arthritis. Or it can be one of many joints involved in a multiple inflammatory arthritis. Pain referred from the hip or back may be felt as a simple knee pain. Problems in the thigh-bone may causes knee pain. In older age, the knee, like the hip, may be affected by osteoarthritis, or wear- and-tear degeneration. In children, unexplained knee pain can be a sign of a very serious hip condition, the slipped epiphysis.

Joint swelling is an important symptom in knee conditions. Because of the complex and extensive synovial lining in the knee, the joint may distend alarmingly, with swelling right round the joint, reaching about seven centimetres above the knee onto the front of the thigh. However, it can also be more subtle. You may also see a small pocket of swelling, perhaps on one or the other side of the joint; or there may be just a slight puffiness on the front of the joint, on either side of the knee-cap. Swelling may occur at the back of the joint, without any visible signs of it at the front. Joint swelling always indicates inflammation. As in the ankle, knee swelling can be caused by gravity bringing the fluid down from some higher tissues: the swelling may track down from the hip joint or some part of the thigh muscles. However, unlike the situation in the ankle, if you have persistent swelling in the knee, which delineates the joint's shape, it is unlikely to be gravitational swelling, and it is very likely to mean that there is something wrong inside your knee.

If the swelling has appeared for no obvious reason, it may indicate that you have an inflammatory or degenerative condition. Your doctor will probably arrange blood tests and X-rays, to decide whether this is so. If the swelling occurs as the result of an injury to the knee, and you are aware of having wrenched it, or fallen on the joint, it is likely that you have damaged one or more of the knee's internal structures, with irritation or damage to the synovial lining. The swelling may come on at the moment of injury, or some hours afterwards.

The knee is very prone to injury, because of its mobility and the variety of stresses we subject it to. The most common type of traumatic injury to the knee is the twisting or wrenching injury. This happens most frequently when your knee is bent, while carrying your body-weight, and you twist awkwardly or unexpectedly. Skiers and footballers are most suspectible to this type of injury, but it can happen to you while walking or running, if you trip and catch your foot, or fall while turning. Any of the knee's structures may be damaged in this type of injury. The full extent of the damage may be impossible to assess immediately after the injury, and may only become evident when the knee subsequently fails to recover its full function.

The knee is also vulnerable to overuse injuries: gradual pains brought on by an activity, which progressively get worse, if you continue the activity. These are the injuries which must be distinguished from the other, more serious, medical conditions which can cause similar pain.

There is never any point in trying to exercise through, or 'run off', the pain of an injury. When you have pain relating to a particular movement or activity, continuing the activity only causes further harm to the damaged tissues. After doing any necessary first-aid measures, your next priority is to obtain an accurate diagnosis of what damage has been done.

In general, the pattern of recovery for tendon and muscle injuries is passive stretching to regain lost flexibility, followed by specific restrengthening exercises concentrating on the injured muscle group, building up to a final stage of functional exercises, in which the injured muscle group works in co- ordination with its surroundig muscles.

Stretching the injured muscles remains an important routine for some time after you have recovered from the injury, to prevent any danger of the muscles becoming tight and then being re-injured. You have to continue stretching the muscles daily, and as the first part of your warm-up before exercising.

For joint injuries, the pattern of rehabilitation usually consists of strengthening exercises for the muscles round the joint, to regain stability, followed by exercises to regain the joint's mobility, leading to the final stage of functional dynamic exercises.

When you plan your programme of rehabilitation exercises, remember that progression is the key principle. Start with little, but often, then gradually increase the amount you do. If you are stretching a muscle group, do two or three stretching exercises at a time, about every hour, if possible, and then try to increase the number of exercises, perhaps doing one or two longer stretching sessions each day. Try to build up to three sets of ten repetitions of each exercise, then increase the number of exercises you do, and then add in gradually increasing weights. Throughout the rehabilitation process, you must avoid painful activities, and concentrate on the exercises directed towards improving function in the injured part. You must not resume your sport until you are sure you can stress the injured tissues without any reaction of pain, swelling, or limitation of movement. When you do resume your sport, you must start with little, and gradually build up to full participation.

The information provided here is not meant to take the place of the complete exam by a physician. If you have an injury we strongly encourege you to get adequate medical care