Introduction:
The enthusiasm for physical activity over the past 20 years has resulted in a steady increase in the number of practitioners and the diversification of sports activities. Although the benefits of sport are commonly accepted (prevention of cardiovascular diseases, a recognized role in the balance of certain endocrine diseases in particular), it is nevertheless also a source of trauma to the musculoskeletal system; these are in marked increase in absolute value but, depending on the specialty, have sometimes decreased, if one relativizes in relation to the number of hours and the number of practitioners.
There are two major groups of lesions: acute (fractures, sprains) – which are not diagnostic and therapeutic – and above all chronic. These can be secondary to repeated acute trauma (mainly ligamentary) or neglected. But, above all, they can be considered specific, coming within the framework of a microtraumatic pathology of hyperuse (overuse syndrome Anglo-Saxons).
In this work we deal only with the chronic lesions which in recent years have been the subject of a very large number of publications, some of which are covered elsewhere in this book. For this reason, we have found it more useful to focus on the specific aspects of clinical examination, frequency and mechanisms responsible for addressing prevention. We then discuss the different types of lesions and indicate some specific examples of this pathology.
General information:
Frequency of lesions:
According to the authors and study protocols (number of subjects, level of practice, mode of data collection), the figures are highly variable.
The incidence is very high for many individual sports: 74% for badminton players, 75% for climbing specialists, 75% for cross-country skiers.
Several studies have shown that one third of the long distance runners had a microtraumatic pathology during a training year. A study conducted under the same conditions among 88 high-level athletes, all specialties combined, revealed an injury rate of 86%, and 67 chronic lesions were diagnosed.
Mechanisms of lesion:
They are related to the repetition of the gesture. Several causes may be mentioned: increased stress (eg fatigue fractures), excessive compression (cartilage lesions, ductal syndromes), excessive traction (tendinopathy, osteochondrosis), repeated friction (tendinopathy, cartilage damage, truncal nerve damage) .
Favorable factors:
They are of two types and must be systematically sought during the clinical examination, the causes being always multifactorial.
Intrinsic factors:
Age:
This is an important factor: many studies confirm the increase in chronic lesions with age, which is hardly surprising considering that these pathologies are more frequent after 2 years of practice. Lesions in the adolescent are above all osteochondrosis and are also studied in this book; they very rarely concern muscles, tendons and ligaments. This indicates the importance at this age of standard radiographs in addition to the clinical examination.
For the older subjects, the question posed is that of cartilage damage and therefore of the risk of arthritic decompensation. It seems that intensive sports practice, apart from any sequelae of acute trauma, is responsible for the more rapid appearance of radiological signs of cartilage damage; but, on the other hand, this possible pathology does not always lead to greater clinical complaints, compared to control groups.
Gender:
The diversification of women’s sport is a relatively recent phenomenon. It is accompanied by an increase in training in quantity and quality. It is now well established that intensive training in some disciplines (dance, gymnastics, running, etc.) leads to frequent hormonal disturbances. It was thus shown that amenorrhoea (most often reversible at the end of training) was accompanied by an increase in the number of stress fractures. In other sporting disciplines, including team sports, there are fewer injuries in women, but a higher percentage of ligaments of the ankle and anterior joint ligament (LCAE) of the knee. Finally, in the same discipline, the distribution of lesions may differ according to sex; thus for sports gymnastics, chronic lesions predominate in the upper limb in men and lower limbs in women. This may be explained in part by anatomophysiological differences (strength, flexibility) but also by the use of different equipment.
Anomalies of the morphotype:
They are often mentioned and represent a factor favoring. For some pathologies, the lesion-morphotype relationship is not or little discussed.
This is the case, for example, of the genu varum association or internal femoral torsion and tendonitis of the fascia lata tensor, tibial periostitis and pronator hindfoot. However, in the majority of cases, the data in the literature are very contradictory. However, the static examination should, if possible, be completed by a dynamic examination exploring the athlete in situation. Thus, a good correlation was found between dynamic hyperpronation and tibial periostitis, increased ankle dorsiflexion, and footbed foot fasciitis. Similarly, cinematographic recording of certain gestures (pedaling the cyclist for example) can be an aid in diagnosis and especially in understanding the mechanisms responsible for the pathology.
Flexibility, or more precisely loss of flexibility:
She has frequently been accused. During the growth spurt it is certainly one of the factors favoring the aggravation of the osteochondroses by mechanism of traction. Similarly, a stiffness of the quadriceps may partly explain a pathology of the extensor apparatus of the knee and some low back pain are associated with a stiffness of the psoas iliac. But again, this factor can not be incriminated. Certain sporting disciplines, such as dance, for example, require a great flexibility musculotendinous and articular and are nevertheless provided with muscular lesions.
Muscle imbalances:
They can be of two types, and concern either the deficit of a muscle group with respect to the opposite side, or an imbalance between the agonist and antagonist groups. This factor has taken a dominant position since the advent of techniques for the exploration of muscle strength by isokinetic dynamometry.
The deficits of force with respect to the contralateral side may be the reflection of an underlying pathology or, conversely, be responsible for this pathology. For example, suffering from the knee extensor can lead to a decrease in the strength of the quadriceps (eg some femoropatellar syndromes) or may be partly due to a deficit of force (eg patellar tendinopathy). However, this deficit must always be objectified, that a difference between 10 and 20% must be considered suspicious, and very probably abnormal beyond 20%.
The imbalances between agonists and antagonists are often referred to as micro- or macrotraumatic factors. The results are at least contradictory. Studies are indeed made difficult by the fact that there are clear differences for subjects of the same age and the same level of practice in relation to the sports specialty. It is also known that values vary over time according to age, for the same discipline.
The question arises whether these imbalances (expressed in relation to age-matched sedentary control groups) may be responsible for the pathology, or whether they are merely the result of training. In the case of flexors and extensors of the knee, it is very likely that the second proposition can be answered; for the shoulder the problem seems more complex and the preferential development of internal rotators compared to external rotators is undoubtedly a factor responsible in part for certain pathologies.
Extrinsic factors:
They concern both the level of practice, the conditions of training (warm-up, intensity of exercise), competition, equipment and soils.
Level of Practice:
It is an important data to take into account. The higher the technical level, the more the specific pathology, microtraumatic, develops compared to the other lesions. Thus in the professional golfer, this pathology represents nearly 80% of the lesions whereas it is less than 30% for an amateur group control. In the latter, excessive playing times leading to fatigue, technical errors as the main causes of the lesions are found.
Physiological aspects of physical exercise:
Neglected or partially realized heating is a recognized factor in the initiation of lesions. Bad or not realized, for example, it is responsible for almost 10% of the traumas of amateur golfers. It must consist of global physical exercises and analytical exercises in relation to the discipline practiced and has for primary purpose the rise in temperature of the skeletal striated muscle. Massages and other protective techniques (synthetic garments, gloves, for example) can be useful adjuvants in cold weather, but are never sufficient on their own.
The warm-up must be accompanied by stretching. Paradoxically, well-conducted studies highlighting the preventive role of stretching, apart from football, are virtually non-existent. Nevertheless, it is recognized that it is better to advise neuromuscular facilitation techniques such as contraction-release than pure static stretching and especially ballistic.Moreover, the specificity of the stretches must be stressed according to the muscles and joints requested preferentially during the exercise.
The training methods must also be systematically studied in terms of quantity and quality. The increase in the amount of training, especially if it is brutal, also leads to an increase in the number of lesions. Thus, for runners, the risk increases beyond 35 to 40 km / week. Intensity is also a factor to be taken into account. Intermittent, intensive exercises with incomplete recovery are more often responsible for muscular or tendon accidents and this in pre-competitive periods, especially for individual sports such as athletics.
As for the competition itself, if it is responsible for a higher number of acute injuries (risk multiplied by 3 in football for example), it is not the same for the microtraumatic pathology, more frequently linked to the (60% of the cases in cross-country skiing and peak of maximum frequency during the preparation phase for the footballer).
We can compare these observations with the research that is indispensable for high-level athletes in a possible overtraining syndrome, a complex picture that is both psychological and physiological, which can be defined as a decrease in physical performance despite the continuation or even the increase of the training amount. This formidable syndrome, which is sometimes difficult to detect, and therefore to treat, may be initially revealed by the appearance of microtrauma. Effort tests on ergometer adapted to the specialty must then show a decline in performance but, above all, a lower production of lactic acid and an increase in oxygen consumption for an identical level of exercise. Finally, there are often signs in favor of a lower recovery. Conversely, biological parameters, and in particular the elevation of enzymes (creatine phosphokinase [CPK]), are rarely usable.
In the same vein, it is necessary to look for possible dietary mistakes: insufficient intake of slow sugars necessary for the glycogenic recharge of the muscle for all activities exceeding half an hour.
These should account for at least 55% of the food intake and the caloric intake should be modulated according to the intensity and number of training and competitions. Insufficient water intakes, which are still frequently found, can also be an indirect cause of certain muscular or tendinous lesions. Remember the need for regular rehydration during exercise and after exercise, with minimum intakes to be about 1 mL for 1.5 kcal / d.
Physical aspects:
The equipment used is precisely and frequently implicated. The most obvious example is undoubtedly that of the tennis racket involved at least partially in the triggering of some epicondylalgia. Particular attention must be paid to the size of the sieve, the tension of the rope, the size of the stick.
The shoe, whatever the sporting specialty, has evolved greatly in its design. The appearance of alpine ski boots with high, molded stems has dramatically reduced the pathology of the ankle and foot … but at the same time has led to an increase in knee trauma, most often acute.
The shoes of the runner on foot are also more and more sophisticated. This has led to a change in the distribution of microtrauma over time with fewer Achilles tendinopathies but more gon- gies and leg pain.
traumatic risk is directly related to the wear and tear of the footwear, beyond 1 700 km. Finally, and despite extensive research, all the problems are far from being solved to propose the ideal shoe, adapted to the morphology and dynamics of the foot, a factor eminently variable according to the subjects. In other words, any change in footwear may be an additional risk factor.
Soils: it has often been blamed, it seems wrong, the hard soils type macadam for the runner on foot. It seems more than the change of soil, including alternate track training, which is the main risk factor, modifying the biomechanics of the foot. This notion is found in football. The incidence of injury is not greater if you train on natural or artificial grass but it increases if the player changes surface frequently. In the case of volleyball, on the other hand, it seems that the incidence of lesions of the knee extensor apparatus, and particularly of the patellar ligament, is higher for athletes training on hard floors.
Finally, other parameters must be taken into account, in particular the increase in resistance to friction, which is responsible for possible blockages of the foot and ankle found on certain synthetic soils, leading to an increase in the number of injuries but not their seriousness.
Classification of lesions:
Upper limb:
Shoulder:
A finer approach to clinical examination, combined with knowledge of sporting gestures, imaging and even arthroscopy, has helped to dismember a number of syndromes and thus improve therapeutic burden and prevention.
We do not deal with instability or the rotator cuff pathology, as these two can be associated. These topics are covered by other authors in this book.
The microtraumatic pathology of the shoulder is frequently found in certain sports disciplines. Throwing sports (baseball, volleyball, handball, javelin, American football, tennis) involve a real kinetic chain in the upper limb. The speed of the launch of the machine depends on the quality of the gesture but also on the speed of the joint itself (more than 1000 ° per second for the launch of baseball for example). This results in maximum stress when arming abduction, external rotation, responsible for intra-articular lesions; then, at the end of the gesture, an explosive work of the internal rotatory muscles must be accompanied by a work in eccentric contraction of the external rotators, which then play a braking role. Any functional imbalance, or poorly programmed gesture, may be responsible, at least in part, for a pathology of overwork such as conflict or tensile injury in the case of involvement of the suprascapular nerves or the long thoracic nerve.
The mechanisms are different for swimming. It is more the repetition of the gesture than the speed that is involved, again, with a preferential solicitation of the internal rotatory muscles. This most often leads to an intricate pathology.For example, a study of experienced butterfly swimmers with a shoulder showed that in only 10% of cases there was an isolated conflict, while 89% of the injured subjects showed signs of instability. Moreover, the muscular activity recorded by electromyogram differs; it is less especially during the phase of push for the small round and increased for the subscapular muscle. During the recovery phase, it is less important for the supraspinous muscle, the upper trapezium bundle and more important for the subepithelial muscle in swimmers with pathology compared to the controls. These imbalances between the different muscle groups of the shoulder represent factors favoring microtrauma.
For other sports specialties we can find the notion of direct microtrauma. Thus, the entry into the water of the diver, the upper member in internal rotation, at high speed (up to 60 km / h), can lead to direct lesions, especially intra-articular lesions. We can compare to this table the microtraumatic lesions related to possible shocks (shot counter abduction external rotation of the hand-baller for example).
That is to say the importance of the clinical examination. As the interrogation reveals the triggering mechanisms of pain, analytical testing must seek a muscular or tendinous lesion sometimes isolated, an often discreet amyotrophy of the supraspinal and subpasal fossae, a reflection of the involvement of the suprascapular nerve, a detachment of the scapula in connection with long thoracic nerve suffering. This examination is complemented by dynamic passive or active maneuvers allowing to recover the various forms of conflict (tests of Neer, Jobe, Gerber, Hawkins …).
The prescription of complementary examinations depends closely on the clinical examination:
– electromyogram in the case of suspected suprascapular nerve involvement, supplemented by magnetic resonance imaging (MRI) in search of a possible compressive paraglenoid cyst;
– ultrasound to analyze muscle and tendon structure;
– arthrotomodensitometry (CT), MRI, or even arthro-MRI exploring both the soft parts and the glenoidal bead;
– more rarely, a bone scintigraphy to diagnose a fatigue fracture (clavicle for the weightlifter, coracoid, humerus during the practice of tennis, baseball or javelin throw).
It is only at the end of this clinical and paraclinical review that a therapeutic decision can be made taking into account the type of injury, age and level of practice. In any case it is always necessary to insist on prevention, namely, maintaining joint amplitudes and maintaining the flexibility as well as the strength of the various muscle groups.
Elbow:
It is an articulation more particularly solicited by gymnastics, wrestling, baseball, javelin throwing, and of course tennis (but this is most often in this case of middle-aged players and technical level).
As for the shoulder, the lesions encountered are directly dependent on the sporting gesture. Thus gymnastics is more frequently responsible for an intra-articular pathology, tennis of a mixed pathology of the external compartment (tennis elbow), sports to launch a pathology of the internal compartment linked to valgus movements traction, decoaptation) which can evolve secondary to an involvement of the external compartment (lesion in compression).
Clinical examination should seek signs of intra-articular suffering (deficit of extension or flexion), muscle or tendon involvement by contra-contracted maneuvers and / or associated ductal syndrome.
Complementary examinations remain to be discussed depending on the clinic.
Of little interest for the tendinous lesions isolated from the external compartment, they allow the search of calcifications to the internal compartment (X-ray, ultrasound) or intra-articular osteochondral lesions (CT or even MRI).
In most cases the treatment is medical, associating rest, deep transverse massages of the tendons, or even infiltrations. But above all it always includes the notion of prevention (warm-up, adapted equipment and possible correction of the technical gesture). It is only in case of failure that a surgical treatment is envisaged at the request which, in any case, must treat all lesions (tendon, intra-articular or even nervous).
Main:
Without a doubt, with the shoulder, the articulation for which the knowledge related to the sport practice have evolved most in recent years. The quality of the clinical examination, which may guide the request for further examination, should be re-emphasized.
Indeed, apart from the sequelae of acute trauma (dislocation, fracture, even sprain), the pathology of the hand is most often microtraumatic and concerns both ligamentous structures and tendons, arteries and nerves.
The sporting gesture is thus:
– is responsible for the pathology;
– reveals an underlying anomaly.
According to the disciplines, the lesions encountered are varied and diverse:
– thus, boxing is more likely to cause osteoligamentary lesions and dislocations of carp bones;
– balloon sports and the fencing of sprains and dislocations of fingers, scaphoid fractures and metacarpals;
– tenosynovitis and wrist sprains are found in divers;
– the skier is primarily concerned with the metacarpophalangeal sprain of the thumb, the tennis player by the fracture of the unciform apophysis of the hooked bone, tendonitis and tenosynovitis, the syndrome of the sensitive branch of the radial nerve;
– the gymnasts present specific tables of radiocarpal impaction which can often lead to lesions of the epiphyseal cartilage in the growing adolescent but also, more rarely, to the distal posterior interosseous nerve syndrome;
– the climbers are confronted with tables of tenosynovitis and a more specific pathology of the digital pulleys;
– Basque pelota specialists have cysts and hygromas responsible for neurological damage, microangiopathy pictures, frequent digital arthroses;
– finally, the cyclists are concerned firstly by the ductal syndromes (median nerve, ulnar nerve).
In the majority of cases, these microtraumatic pathologies are linked to the repetition of the gesture, to the modification of the technique, to an inadequate material, or even to a simple change of training conditions. These factors are therefore systematically sought with the aim of improving prevention.
Spine:
Lesions of the cervical spine:
Microtraumatic, they can take the form of common cervicalgia, sprains and later of arthrosic decompensation. They are frequently found among footballers, basketball players and especially rugby players and American footballers; but also during the practice of diving, aviation and mechanical sports.
If these tables do not show any particularities in relation to nonsportives, the possible risk of dramatic neurological complications due to involvement of the spinal segment in sportsmen who are very muscular and too often accustomed to presenting tables of cervicalgia repeatedly must be kept in mind. This means the importance of a complete clinical examination and a quality radiographic assessment, including, if necessary, the prescription of dynamic images and the management by any specialized team if need be.
As with the other joints already studied, attention must be paid to the prevention of injuries by improving the equipment, by insisting on muscular reinforcement, and in some cases by modifying the federal regulations.
Lumbar spine:
It alone represents, for certain sports disciplines, more than 10% of the reasons for consultation in the form of acute or chronic low back pain, and more rarely lumbosciatalgia. The causes must be systematically investigated: rarely a pure disc herniation, more often a muscular pain, an intervertebral disturbance of the posterior articulations, a spondylolisthesis, an isthmic lysis and, in the adolescent, an epiphyseal dystrophy of growth.
The sporting gesture itself can favor this pathology by movements, either of hyperextension (sports gymnastics, rhythmic gymnastics and sports, dance), or in rotation (throws, ball hitting), or in compression (weightlifting). Indirectly, the stiffness of the iliopsoas muscle found in certain sports specialties (especially football) can lead to secondary hyperlordosis, a factor favoring low back pain.
In any case, the question remains about the frequency of sports-related back pain. In the teenager, for example, we know that there is no difference between boy and girl, sportsman or not. On the other hand, in the sports group, the frequency increases with the amount of training and probably the loss of suppleness of the hip flexors. Finally, the incidence of spondylolysis is higher in female gymnasts.
Spondylolysis deserves special attention. Known in all populations, it is more frequently found for certain sports disciplines. In order of frequency, diving, wrestling, weightlifting and gymnastics are the sports most concerned. It seems to us especially important to insist on the acute or subacute lumbago picture, triggered by the exercise and reflection, in the adolescent, of a probable fracture of fatigue of the isthmus. The diagnosis, at the very beginning, can be difficult even on shots of three quarters of quality. Bone tomoscintigraphy is then an examination of choice, possibly supplemented by a CT examination to quickly set up medical treatment (rest, immobilization by corset) and thus avoid the risk of evolution towards pseudarthrosis and chronic low back pain.
Basin:
The clinical picture by far the most frequent is that of pubalgia, a subject treated elsewhere in this book. However, the sacroiliac joints should not be systematically examined. They are very mobile, very closely related to the biomechanics of the lumbar spine and pubic symphysis. They are subjected to severe and repeated stresses, which can lead to acute (fatigue fracture) or chronic symptoms. Most often, it is the complementary examinations that confirm the diagnosis (bone scintigraphy and especially MRI).
Inferior member:
Lesions are equally varied, but more frequent than in the upper limb.
Hip:
Intensive sports practice is a recognized factor in the development of early osteoarthritis if pre-existing morphological abnormalities exist.
Any coxopathy of the young subject must therefore lead to a complete clinical and radiological assessment and interpreted according to the sporting practice (dance, collective sports, running).
Physical activities are also the most frequent mode of revelation of the hips with jump, subject treated otherwise. This extra-articular pathology must be well known; more frequent in women, and especially the dancer, it is pathological only if it is accompanied by painful phenomena. It must be well differentiated from other possible causes of intra-articular jump (osteochondral lesion, lesion of the bead, osteochondromatosis), external projections (iliotibial tract, gluteus maximus) or posterior (biceps tendon).
Thigh:
The lesions concern primarily the skeletal striated muscles for which an entire chapter is reserved in this book. These occur in two main circumstances: direct shock or intrinsic mechanism (the most frequent case), including a notion of contraction on an eccentric mechanism.
The major risk of direct shocks (football, rugby, motorcycle fall) is represented by the appearance of a large intermediate muscle hematoma whose evolution towards ossifying myositis is sometimes very rapid. This implies the importance in this case of an early therapeutic management and the need for an ultrasound assessment.
The intrinsic lesions are eminently variable in frequency according to the sports discipline. Almost non-existent in basketball, they account for more than 20% of football accidents (adductors and hamstrings before 20 years, quadriceps between 20 and 30 years old mainly) and are often severe (75% of stage III lesions). As far as athletics is concerned, it is mainly the disciplines of jumps and speed that are concerned, and more particularly the hamstrings with the risks of sequelae, especially fibrosis sometimes difficult to treat.
Physical exercise is also, and more and more often, the revealer of neuromuscular diseases, initially in the form of cramps and fatigue to exercise. This table should be well known, enabling enzymatic deficiencies to be detected that formally contraindicate intensive physical activity and even cause real syndromes of intolerance to exercise. Gradually increasing exercise stress tests, carried out in the laboratory and programmed before heavy examinations (muscle biopsy, nuclear magnetic resonance) allow an approach to these diseases by evaluating the aerobic capacities and by measuring certain biological parameters. An early elevation of the lactate suggests a possible mitochondrial involvement. Conversely, the absence or low production of lactic acid at maximum stress suggests glycogenosis.Finally, the clear elevation of CPK is found in the context of myopathies (ensuring that no intense exercise has been performed in the previous 48 hours), apart from any notion of muscle trauma in the days preceding the dosage.
Apart from muscular pathology, it is necessary to think systematically to eliminate a ductal syndrome. The diagnosis is above all clinical, the electrophysiological examinations being very often negative. The pains triggered by exercise, on the external surface of the thigh evoking the involvement of the lateral cutaneous nerve, on the internal surface at the root that of the large abdominogenital nerve or the obturator nerve. For the latter it is necessary to seek pain from the root of the thigh during the stretch-contraction of the adductor muscles associated with a hypoesthesia located in the middle third of the inner face of the thigh.
Finally, for several years, there is known a frequent vascular cause of thigh pain: the external iliac endofibrosis.Described in the high level cyclist, it was found, but at a much lower frequency in athletics (running) and triathlon. This picture is a thigh pain triggered by intense exercise, sometimes in the form of pseudo-muscles, the athlete describing an impression of swelling and frequently weakness of the entire lower limb. All these signs disappear quickly if exercise decreases in intensity. Diagnosis should always be confirmed by an arterial Doppler examination. The latter, strictly normal at rest, is pathological only if it is carried out immediately after an ergometric bicycle test which has triggered the painful symptomatology. In case of a confirmed sports handicap, and after arteriography, only the surgical treatment adapted to lesions and to the age allows the cure.
Knee:
It is the joint most frequently reached, whether it is the extensor apparatus of meniscoligamentary structures, cartilaginous or tendons.
Expander apparatus:
PWF is the most common reason for consultation before the age of 20 years. Sport is only one of the symptoms of morphotypic abnormalities (genu valgum, genu recurvatum, patella alta, patella baja). The table of patellar instabilities is treated elsewhere. The difficulty consists in adapting sporting activity to the actual or supposed handicap, taking into account the psychological context – the alleged symptomatology is not always correlated with clinical and paraclinical findings. On the other hand, it is necessary to detect true instabilities, fortunately more rarely, by young athletes who are very motivated, especially in the fields of dance, football, volleyball and high jumping.
All in all, a mild femoropatellar syndrome of the adolescent summarizing in a clinical picture without radiological sign is exceptionally a reason for dispensation of physical activities and sports. Most often, this symptomatology fades at the end of growth. On the other hand, certain unsafe sports practices (pivotal sports, pulses) can be discussed when there is instability in the frontal plane or a patella height anomaly; the possibility of cartilaginous lesions and of osteoarthritic decompensation after the age of 30 years should be taken into account.
Quadriceps tendinopathies are relatively rare, easy diagnosis and treatment. They come under the jumper’s knee, basketball, volleyball and high jump. They can be isolated during the practice of sports such as cycling, they should not be confused with possible fractures of knee fatigue found in cross-country skiers or runners. The diagnosis is then asserted by bone scintigraphy.
Patellar ligament tendinopathy is the prerogative of pulse sports (high jump, volleyball, basketball) and reaches its peak frequency between 15 and 25 years. Pains occur first after physical exercise, then at the beginning of the exercise and finally become permanent according to the classification of Blazina. In stage I and II medical treatment most often gives excellent results (sports rest, anti-inflammatory treatment, physiotherapy and deep transverse massages, and secondarily, stretching). In stage III, the results are much more disappointing, corresponding to nodular or cystic lesions on ultrasound and an intratendinous hypersignal at the MRI found in more than two thirds of the cases in the upper third of the tendon. For advanced and motivated athletes, the surgical indication (combing of the tendon associated with a tip of the patella tip) should be considered, which gives more than 80% of good and very good results with a return to the initial level towards the tenth month postoperatively.
Meniscoligamentary structures:
· Meniscal lesions isolated
They have little specificity in sports practice. However, the postoperative risks of quadriceps should be stressed, even after arthroscopy, in relation to pain and which could lead to rapid loss of strength in the first days, above all at the expense of slow-twitch red fibers I). This explains the importance of an early program combining pain control and remusculation followed by secondary rehabilitation to ensure a satisfactory outcome in the medium and long term. As for the choice of the operating technique, arthroscopy allows on average a faster recovery of training and competition;but there seems to be no difference in the evolution towards osteoarthritis. This is far from negligible as it reaches 29% of a group of footballers reviewed over 15 years after meniscectomy. In fact, it seems that the primary factor in the resumption of sport at the same level after meniscectomy, even partial, remains the existence or not of cartilaginous lesions. In the case of associated lesions, particularly for collective sports, residual pain, episodes of hydarthrosis, are much more frequent and greatly reduce the chances of recovery.
· Ligament lesions
They have been the subject of the largest number of publications over the last 20 years. A chapter is reserved for them in this work.
We therefore merely address a number of points which are more specific to sports practice concerning the most frequent lesion, namely the antero-external cruciate ligament, and its possible consequences in the medium and long term.
First of all the sports concerned: all the activities classified as pivotcontact (football, rugby, handball, basketball, American football …) are of course concerned as well as alpine skiing (and in this case regardless of level of practice).But all disciplines requiring the use of the lower limbs may be more or less concerned: poor reception during jumping, falling bicycle without releasing the bindings for example.
Age is an important factor: in teenagers, before the growth cartilage is closed, the lesions are much more rare, but they are clearly increasing, and concern above all sports such as skateboarding, gymnastics, mountain biking, more than team sports. However, this type of lesion still raises difficult questions about the management of the lesions (functional treatment most often, surgical treatment from the outset while respecting the cartilages of growth
rarely), especially as at this age the associated medial and lateral meniscal lesions are much more frequent than in young adults.
The treatment itself is still the subject of much discussion: in our opinion it must depend on the notion of instability, age and level of practice.
Instability is the major symptom to be differentiated from laxity. Other causes of instability, namely meniscal, cartilaginous and femoropatellar, should be systematically eliminated and the ligamentous origin should be confirmed by the search for the external rotatory outgrowth. It seems that it is this symptom, that is, instability, that is largely responsible for the evolution towards osteoarthritis.
Age and level of practice: In our opinion, the young adult practicing pivot-contact sports, and a fortiori professional, must benefit from surgical treatment (intra-articular or mixed plasty) as soon as the knee is dry and little pain. It is certainly not the case of the occasional sportsman (the typical example being the skier, non-athlete otherwise) which, in our opinion, must first benefit from a conservative treatment well conducted; which in no way implies culpable therapeutic abstention. Certainly, numerous studies tend to show that “the natural history of damage to the anterior cruciate ligament not operated” evolves in a few years towards the instability, meniscal and cartilaginous lesions.However, these most often relate to patients with secondary complications. In other words, there is not, to our knowledge, any randomized study comparing long-term conservative treatment and surgical treatment. There remains an important point to be clarified, namely the associated meniscal lesion. If certain lesions, especially of the posterior horn of the internal meniscus, have an indisputable healing potential, it does not appear logical in the event of an arthroscopic decision to place an indication of meniscectomy without repair of the central pivot. It is known that in the medium and long term the risks of evolution towards osteoarthritis are much more important.
In recent years, and in view of the increase in the frequency of lesions of the antero-external cruciate ligament, the indication of orthoses has been frequently discussed. From the outset, it must be stressed that it is difficult to carry out scientifically indisputable studies. To date, there are some important principles: there is no evidence of the preventive role of these orthoses in relation to the risk of injury, the use of an orthosis modifies the kinematics of the step during the race and proprioception; it results in greater energy expenditure and faster fatigue for equal work. Its effectiveness is by no means proven, and this whatever the type of orthesis, in postoperative.
Tendonitis:
The generalities concerning the physiology and microtraumatology of the tendons are studied elsewhere. For the knee, they concern primarily runners, cyclists, and therefore triathletes.
The tendonitis of the crow’s feet, on the inner surface of the knee, is virtually non-existent in the athlete, apart from any intensive rehabilitation program. A painful picture of the median compartment must therefore above all evoke a meniscoligamentary or osteocartilaginous pathology.
The tendonitis of the femoral biceps, which poses no diagnostic difficulty, is the prerogative of the cyclist.
Fascia lata tendonitis is more frequent and is found in pedestrian riders (the incidence according to the studies is estimated between 1.6 and 12%). It is a pain of the external compartment very localized and triggered by the repeated movements of flexion-extension (so-called “wiper” syndrome) and found on palpation. This is a typical friction pathology of the test strip. The diagnosis remains clinical, the complementary examinations (ultrasound, even MRI) are only possible complement to the search for a bursitis. In addition to anomalies in the morphotype (genu varum, internal femoral torsion, inferior length of the lower limbs), it is recognized that: excessive mileage associated with less experience in running, , swimming), track training and a lower ability to dampen the contacts during the deceleration phase of the pace, and finally, a lower pronation of the hindquarters during the race.
Treatment is primarily medical (rest, non-steroidal anti-inflammatory drugs and infiltration loco dolenti in case of failure), very rarely surgical (partial resection, posterior strip), by systematically associating the correction of risk factors.
Popliteal tendinitis is more rare but should not be confused with external meniscal suffering or other tendinitis. It is triggered by bending maneuvers in unipodal support.
Tubular segment:
The pain of the leg revealed by the practice of sport is an increasingly frequent reason for consultation. They concern the Achilles tendon, the muscles, the bones, the veins and the arteries and, finally, the truncular nervous pathology.
Achilles’ tendon:
It is the subject of two special articles concerning clinical and imaging. It is the most common tendon in many sporting disciplines, but in the first place running.
The picture is often that of acute or chronic tendinopathy. Achilles tendon rupture is mainly found after 35 years, but the risk seems to be much greater at the age of 20 in certain disciplines practiced at the high level and preferentially impulses (high jump, gymnastics, sports acrobatic).
Muscle wasting:
Lower lesions of the medial gastrocnemius are the most frequent, found mainly after 30 years in foot racers, but also in collective sport. Particular attention should be given to musculotendinous disintegration (tennis leg), which is much slower in cicatrization, and which can cause a surgical indication in the young subject.
More rarely, there will be high lesions of the medial gastrocnemius, always of small size and difficult diagnosis. They should not be confused with tendinitis or popliteal cyst. In this case, ultrasound is often necessary for diagnosis.
Chronic Home Syndromes:
Described to other limb segments (especially forearms for windsurfing or motocross specialists), they primarily concern the leg segment (antero-external lodge and, more rarely, deep posterior lodge). They are the subject of a special article. This pathology is frequently found in long distance runners, walkers, skaters on rollers mainly. It can be triggered suddenly in other disciplines such as team sports, in connection with a sudden increase in training (eg strength training programs).
Supernumerary muscles and accessory muscle bundles:
Known for a long time by anatomists, they can, during intense sports practice, reveal themselves in the form of a painful syndrome of effort of the type of heaviness, even pseudocampus, and more rarely of a table of intermittent claudication. In the tibial segment, one recognizes the accessory soleus; but other muscles may be involved (fibular, anterior tibial, medial gastrocnemius in particular).
In the popliteal cavity, it is necessary to know the existence of a semi-membranous muscle.
The clinical examination finds comparatively (when the anomaly is unilateral) an increase in volume of the segment of limb concerned, more readily found during the contraction against manual resistance of the muscle. The diagnosis is confirmed by ultrasound and especially comparative MRI. The electromyogram, when it is practiced, confirms the muscular structure of the swelling. The only effective treatment, especially in the case of neurological or vascular compression, consists at least in a fasciotomy and, most often, in the excision of the beam responsible for the pathology.
Fatigue fractures:
They can be found in all bones (10% of sports-related trauma), depending on the discipline; but again, with greater frequency in the tibia segment and especially in the tibia. They are studied elsewhere.
These are, first, endurance athletes who are affected; but all disciplines may be involved. The diagnosis is confirmed early by the 99 m scintigraphy technetium which reveals an hyperfixation from the first days. The importance of clinical correlation / imaging, however, should be emphasized, as hyperfixation focuses are very frequent in athletes, especially in the tibia and the tarsal bones.
Tibial periostitis:
Median pain of the middle third-third lower third of the tibia corresponds to a pathology of insertion of the plantar flexor muscles and, in particular, of the posterior tibial. Triggered by physical exercise and favored by a pronatory hindfoot, it is limited to a painful picture, found again on palpation, and calmed by the rest.
Treatment combining decreased physical activity, NSAID and correction of morphotypic disturbances of the hindfoot often gives excellent results.
Failures should seek a deep lodge syndrome, or even a fatigue fracture. For some authors, there is even a strong entanglement between these different tables. The diagnosis is then specified by scintigraphy and MRI.
Vascular pathology:
It is frequently related to a supernumerary beam or an abnormal path of the vessel.
Exceptionally, one finds the typical picture of the syndrome of the soleus accompanied by heaviness or even edema of the calf, triggered by physical exercise and corresponding to a venous compression at the level of the arch. The diagnosis is confirmed by the profile phlebography associated with dynamic maneuvers.
Trapped popliteal artery syndrome is the prerogative of the young athlete (walker, cyclist in particular). The table is that of an intermittent claudication of effort which is confirmed by the arterial doppler examination, knee extension with active dorsiflexion of the ankle and, secondarily, arteriography. Here again the treatment can only be surgical, lifting the anatomical obstacle.
Ankle:
It is with the knee the joint most frequently reached.
A sprained ankle:
It is above all the sprains of the external compartment but we must not neglect the search for lesions more rare (anterior, internal, subtalar sprains). The clinical examination and the conduct to be taken are now perfectly codified. It is mainly collective sports that are concerned. First and foremost basketball and volleyball, but also football, discipline for which the tackle is responsible for more than 50% of the initial sprains.
We must insist on the management of the first accident, the recurrence making the bed of the instability and the associated lesions. The functional treatment is based on the respect of the healing times and the secondary quality of the reeducation (musculation and proprioception).
There remains an important question, the role of strappings, even orthotics, in the prevention of sprains. To date, it seems that no means of restraint can prevent the initial accident. On the other hand, the effect seems positive on recidivism, at least as regards frequency. The results seem to be much more questionable with regard to gravity.
False ankle sprains:
Under this term we have regrouped a certain number of lesions which must be systematically evoked in the framework of the differential diagnosis. Indeed, some intra-articular lesions can be revealed in the form of pseudo-instability linked to the painful phenomena. Standard radiography is often faulted. Bone scintigraphy may be a good examination of descrambling in search of a focus of localized hyperfixation. It is the arthroscanner, or better, the MRI, which confirm the diagnosis namely, mucosal cyst, partial necrosis, osteochondral fracture or osteochondritis.
Syndromes of the anterior or posterior crossroads (often associated) represent another aetiology to be sought, especially in the soccer player and the dancer. The syndrome of the anterior intersection manifests itself in acute pain during a hyperextension movement, a phenomenon which is usually fleeting. The radiograph reveals an ossification of the anterior tibial margin, associated or not with an ossification of the collar of the slope and with foreign bodies intra-articular. The posterior syndrome is triggered by movements in dynamic plantar flexion and corresponds to a trauma of the postero-posterior tubercle of the talus. It is often associated in the dancer with a tendonitis of the hallucis long flexor. The radiograph confirms the lesion but must always be interpreted according to the clinical picture. In all cases, these syndromes regress most often due to sports rest associated with anti-inflammatory treatment and physiotherapy;in the event of failure, treatment is proposed by infiltrations and, much more rarely, surgical treatment.
Tendinous lesions:
They are studied elsewhere, they concern fibular tendons and the most frequent array of acute or chronic luxation.This type of lesion, previously found in skiers, is now observed in many sporting disciplines (dance, gymnastics, team sports).
The lesions of the posterior tibia, and particularly the partial ruptures, are more rare but must be perfectly known. The clinical picture may occur in an acute or subacute mode during a dorsiflexion and eversion movement, but more often in a more insidious manner in the case of partial ruptures. The diagnosis evoked by palpation and resistance testing of the tendon is confirmed by tenoscanography or MRI. Medical treatment remains very disappointing in the athlete, even in the event of partial rupture, and it is therefore the surgical treatment that should, in our opinion, be recommended.
Foot:
Impairment of the plantar aponeurosis:
They affect all sports but mainly run (7 to 9% of traumas in certain series) and are favored by the supinator stile. It is necessary to differentiate the pathology of insertion on the calcaneus (plantar myopneurosis), the plantar fasciitis itself (pain in relation to the internal arch), or even the rupture of the aponeurosis. If the diagnosis is primarily clinical and medical treatment, MRI can be very useful before any surgical decision is made, which is only taken after at least 3 months of well-conducted medical treatment.
Osteoligamentary disorders:
They are frequent but do not show much diagnostic and therapeutic specificity.
· Sprained joints of the mediusar joints and especially of Lisfranc They are found in the footballers (mechanism of direct shock, during a shoot countered). The risk of sequal pain is potentially very high. The radiographic evaluation is therefore systematic, exploring the articular interlining and in search of an eventual associated osseous removal.Consequently, this type of lesion should be treated like any sprain and should not be confused with a simple superficial trauma, under pain of a random chronic course.
· Fatigue fractures
Sesamoids and metatarsals can be affected during running, dancing and jumping – tarsal bones during the race, including sprint for navicular bone. For the latter table, the delay of the radiographic images is known. Early bone scintigraphy is therefore imperative to implement orthopedic treatment; the risk being the evolution towards the pseudarthrosis necessarily requiring surgical management. These fractures of fatigue are favored by morphological abnormalities (Greek foot or Egyptian foot) and synostoses which are suspected by clinical examination (loss of mobility) and confirmed by X-rays, and especially the CT scan.
· Pathology of the first ray and, in particular, of the first metatarsophalangeal
Of microtraumatic origin, it is favored by the strike of ball and the direct traumatisms in the footballer. It is mostly found in dancers, either in the form of hypermobility, or in the form of a hallux rigidus. These lesions, which are often very disabling, will have to benefit from all medical treatments and possible local protection before a surgical decision.
The management of sports trauma must be complete. The diagnosis is above all clinical and reinforced if necessary by other examinations (usually imaging), performed according to the pathology. The diagnosis made, the treatment, most often medical first-line, must always take into account the specificity of the sporting gesture; in order to correct any anomalies (realization of the gesture, material, training) that make the bed of these technopathies of overwork.
