Common Sports Injuries: Diagnosis and Treatment Options

Educational Objectives

The goal of this program is to improve management of common sports injuries. After hearing and assimilating this program, the clinician will be better able to:

1. Recognize the signs and perform appropriate examinations to diagnose shoulder impingement, femoroacetabular impingement (FAI) syndrome, and patellofemoral pain syndrome.

2. Distinguish morphologic FAI from FAI syndrome.

3. Elaborate on the importance of physical therapy and conservative care for management of shoulder impingement, FAI syndrome, and patellofemoral pain syndrome.

Summary

Shoulder impingement: shoulder pain is the second most common musculoskeletal complaint next to low back pain; shoulder impingement syndrome is the most common etiology of shoulder pain; impingement is not a specific injury to one structure; represents a combination of symptoms, examination findings, and radiological signs attributable to compression of structures around the shoulder joint that occurs with shoulder elevation; structures involved include supraspinatus tendon and subacromial bursa

Neer classification of shoulder impingement: stage I — rotator cuff tendinitis and bursitis in acute phase; stage II — fibrosis and thickening of rotator cuff tendons and subacromial bursa; stage III — partial or complete rotator cuff tear; degenerative tears as a result of impingement are more common than acute traumatic injury

Etiology: primary impingement — structural changes mechanically narrow the subacromial space; outlet impingement is bony narrowing on cranial side of subacromial space; nonoutlet impingement results from increase in volume of subacromial soft tissue on caudal side; compression occurs when the shoulder is elevated; can result in symptomatic subacromial bursitis or rotator cuff tendinopathy; secondary impingement — results from a functional disturbance leading to failure in centering the humeral head (eg, ligamentous laxity, underlying shoulder instability)

Presentation: most commonly shoulder pain and weakness; pain is often localized to the deltoid area or lateral arm; sometimes radiates down the upper humeral region; shoulder impingement should not give true radiculopathy with pain radiating down into elbow, forearm or hand; pain may occur at night when lying directly on the affected shoulder; pain is always exacerbated by overhead activities

Examination: inspect the shoulder girdle; systematically palpate structures around the shoulder joint; evaluate range of motion (ROM); active ROM is often limited because of pain but not restricted on passive movement; all affected structures are extra-articular with impingement; neurovascular examination is important; shoulder pain with associated neck pain radiating down the arm is often a manifestation of cervical radiculopathy

Special tests: physical examination is very sensitive for identifying shoulder impingement but often cannot reliably distinguish among specific causes; Hawkins impingement test — 90% sensitivity; passively forward flex the shoulder to 90° with elbow bent at 90° and internally rotate the shoulder; low specificity; Neer impingement test — passive test; internal rotation of the shoulder followed by forward elevation will elicit pain at shoulder girdle; if the patient has pain in thumb down position with the shoulder internally rotated, then perform the test again with palm up, externally rotating the shoulder; with classic Neer impingement test, some reduction in pain can be seen; high sensitivity with poor specificity; Macdonald et al (2000) showed a combination of both tests has high negative predictive value, >90% for bursitis and ≈90% for rotator cuff tear

Diagnostic imaging: initially unnecessary without red flags; consider if no improvement after 4 to 8 wk of conservative treatment; most valuable views include anteroposterior (AP) view of the glenohumeral joint (Grashey view), axillary view, and outlet view; magnetic resonance imaging (MRI) is not initially indicated; consider if conservative treatment fails; gold standard for detecting complete rotator cuff tear; high sensitivity for rotator cuff tendinopathy; musculoskeletal ultrasonography is accurate for evaluating rotator cuff tendons and subacromial bursa; high sensitivity and specificity for full thickness rotator cuff tears; less sensitive for partial thickness tears; high specificity and sensitivity for subacromial bursitis and rotator cuff tendinopathy

Management: strongest evidence for rehabilitation exercises; activity modification (eg, avoiding aggravating activities) is helpful; focus of rehabilitation is to improve shoulder ROM and strengthen rotator cuff, scapular stabilizers, and core musculature; study showed a structured rehabilitation exercise program had more successful outcomes compared with unstructured exercises; not enough evidence to routinely support laser therapy, acupuncture, or shock wave treatment; some trials have demonstrated short-term benefits from subacromial glucocorticoid injections; long-term benefit has not been demonstrated; speaker uses steroid injections to reduce acute pain and facilitate physical therapy (PT); studies show ≈70% to 90% of patients respond favorably to conservative treatment; recommended to continue conservative measures for 3 to 6 mo as the initial treatment choice; consider surgical intervention for those who do not respond; some studies concluded that surgery provided no improvement in pain, function, health related quality of life (QOL), or return to work; decompression surgery was associated with frozen shoulder in certain trials; criticisms included heterogeneous patient populations, short-term follow-up, small sample size, amount of group crossover, experience level of surgeons, and failure to standardize surgical technique

Femoroacetabular impingement (FAI): pathological contact between femoral head-neck junction and acetabular rim during functional hip ROM; may be caused by aspherical femoral head (cam morphology), overcoverage of the femoral head (pincer morphology), or a combination of both (mixed); with cam deformity, decreased offset of the femoral head-neck junction causes impingement on hip flexion; with pincer deformity, impingement over the superior aspect of the joint can occur with hip flexion; research suggests a strong association and a dose-response relationship with intensive sports activity during adolescence, particularly in men; increased bone development may be a physiological adaptation to loading; lower prevalence in women; possible genetic component

Distinguishing FAI from FAI syndrome: only a small proportion of people with FAI morphology develop symptoms; FAI syndrome is defined as a triad of symptoms, clinical signs, and imaging findings; patients present with movement-related symptoms and groin pain; insidious onset; most notable after sitting with hip flexed to 90° for long period of time; decreases when rising to standing position; physical activity is affected as symptoms progress; other symptoms include clicking, catching, locking, stiffness, restricted motion, and instability; C sign is a classic feature of FAI syndrome; painful area extends from lateral hip into the groin; 90% have groin pain; 70% have lateral hip pain

Examination: many patients have a Trendelenburg gait because of weakness of the hip abductors on the affected side; pelvis drops, and patient lurches toward the affected side to compensate; palpate around the hip girdle; hip motion may be restricted; patient may have associated muscle weakness around the hip girdle

Flexion, adduction, and internal rotation (FADIR) test: also known as anterior impingement sign; flexing hip to 90° and then internally rotating will provoke pain

Diagnostic imaging: x-rays are very helpful; AP pelvis weight-bearing view, AP and lateral view of symptomatic hip, frog leg lateral or modified lateral view; consider MRI if x-rays are not definitive; MRI can provide valuable information but may show incidental findings not causative of hip pain; clinical correlation is required

Management: conservative care — includes patient education, lifestyle and activity modification, short course of analgesics, and watchful waiting; rehabilitation — mainstay of treatment; PT often focuses on improving hip stability, neuromuscular control, strengthening muscles around hip girdle, and improving ROM and abnormal movement patterns; systematic review showed supervised PT was more effective than simple unsupervised exercise regimens; surgery-for those not responding to conservative treatment for 3 to 6 mo, surgery is an option; arthroscopic surgery is effective; surgery typically involves excising impinging bone and addressing concurrent injury to labrum or cartilage; advanced osteoarthritis (OA; eg, joint space narrowing <2 mm) is an absolute contraindication for surgery; relative contraindications include mild hip OA, advanced age, ligamentous laxity, and morbid obesity

Patellofemoral pain syndrome: also known as anterior knee pain or chondromalacia patella; defined as pain occurring around or behind the patella and aggravated by ≥1 activity that loads the patella during weight-bearing on a flexed knee

Causes: patellar maltracking results when tightness of the lateral retinaculum or iliotibial band and contractions of quadriceps muscles pull the patella laterally; enhanced by dynamic valgus; pain can also be caused by excessive patellofemoral joint loading; patellofemoral compressive forces increase with knee flexion; other causes include conditions that cause contracture of hamstrings, increased stress across the patella, and psychological factors

Examination: pain and stiffness can be increased by prolonged sitting with knee flexed (theater sign); should not have effusion, redness, or warmth; sensitive findings include tenderness of patellar facets and pain with squatting; patellar tilt test (most specific) involves elevation of the lateral edge of the patella; patella tilts downward in many cases; examiner may be unable to move the lateral edge of the patella into neutral position; single leg squat test can assess dynamic control of the lower leg; pelvis tilts, femur internally rotates, and tibia rotates, leading to dynamic valgus malalignment

Diagnostic imaging: unnecessary without red flags; consider x-rays if no improvement after 1 to 2 mo of conservative treatment; weight-bearing AP view, lateral view, and axial view of patella; merchant and sunrise views are the most commonly performed; MRI is reasonable to assess for pathologies that can mimic patellofemoral pain

Management: rest and activity modification; NSAIDs can be used for short-term pain relief; no role for long-term NSAIDs; PT is the cornerstone of treatment; exercise therapy is effective for reducing pain, improving functional ability, and enhancing long term recovery; effective exercise therapy programs target hip, external rotators, hip abductors, and knee extensors; PT focuses on trunk stabilization, core strengthening, and active stretching of the hamstrings; orthotics, patellar taping, and bracing may provide benefit when used in combination with PT; consider surgery only for patients who fail exhaustive conservative treatment and have evidence of lateral patellar compression or patellar instability; a significant number of patients may worsen after surgery

Readings

Dernek B et al. The incidence of impingement syndrome in cases of cervical radiculopathy: an analysis of 220 cases. J Back Musculoskelet Rehabil. 2020;33(3):363-366. doi: 10.3233/BMR-181354; Evans JP et al. Frozen shoulder after simple arthroscopic shoulder procedures: what is the risk?. Bone Joint j. 2015 Jul;97-B(7):963-966. doi: 10.1302/0301-620X.97B7.35387; Hughes P. The Neer sign and Hawkins-Kennedy test for shoulder impingement. J Physiother. 2011;57(4):260. doi: 10.1016/S1836-9553(11)70061-3; Kendall KD et al. Steps toward the validation of the Trendelenburg test: the effect of experimentally reduced hip abductor muscle function on frontal plane mechanics. Clin J Sport Med. 2013 Jan;23(1):45-51. doi: 10.1097/JSM.0b013e31825e66a1; MacDonald PB et al. An analysis of the diagnostic accuracy of the Hawkins and Neer subacromial impingement signs. J Shoulder Elbow Surg. 2000;9(4):299-301; Manske RC et al. Examination of the patellofemoral joint. Int J Sports Phys Ther. 2016 Dec; 11(6): 831–853; O’Rourke RJ, El Bitar Y. Femoroacetabular impingement. StatPearls Publishing. 2020 Jun 29. https://www.ncbi.nlm.nih.gov/books/NBK547699/; Rixe JA et al. A review of the management of patellofemoral pain syndrome. Phys Sportsmed. 2013 Sep;41(3):19-28. doi: 10.3810/psm.2013.09.2023; Singh B et al. Current concepts in the diagnosis and treatment of shoulder impingement. Indian J Orthop. 2017;51(5):516-523. doi:10.4103/ortho.IJOrtho_187_17.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Anish was recorded virtually at Update in Internal Medicine 2020: Advances Changing Practice, held October 22, 2020, and presented by the University of Pittsburgh School of Medicine, Department of Medicine and Office of Continuing Medical Education. For information about CME opportunities from the University of Pittsburgh, please visit https://cce.upmc.com/. Audio Digest thanks the speakers and sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OR440902

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.