After the injury, getting back in the game

Stuart Montgomery, M.D.
Orthopedic surgeon, Providence Orthopedic Institute

As a sports medicine-trained physician specializing in knee and shoulder injuries, I find there is nothing more rewarding, and occasionally exhausting, than helping young athletes overcome their injuries and get back into the game.

Over the years, however, sports seasons have grown in intensity, frequency and duration, putting greater demands on young bodies. Treating the high school and college athlete requires unique and variable skills. Clinicians are one part diagnostician, one part psychologist, one part coach and one part parental adviser.

Many pressures are brought to the physician from the parents, the coaches and the players themselves. Athletes want to play, and parents and coaches may be blinded by athletes’ talents as they push to return to sport. We too want to help our patients return to the sport they love while also keeping their best interests in mind.

Finding the cause

As we were taught in medical school, a detailed history and physical exam give us 95 percent of what we need to make a differential diagnosis. With sports injuries, the history should include these questions:

  • Was the onset of the trauma insidious or acute?
  • Can the athlete play through the injury?
  • Are mechanical symptoms present, such as catching, popping or instability?
  • What’s the timing and degree of swelling?
  • Is this an initial or recurrent injury?

If the athlete is a star pitcher who plays in multiple baseball leagues, it’s likely that his shoulder soreness is caused by overuse, and will respond to rest and physical therapy. If, however, a young female soccer player experiences acute instability and swelling to her knee while trying to pivot on a wet field, she may be suffering from an acute ligamentous injury. An injury affecting the anterior cruciate ligament is of particular concern.

A careful (and gentle) physical examination will yield our next piece of diagnostic information. As a high school soccer player, I hyperextended my knee and was taken to the ER. The orthopedist asked how my knee felt, and as I was halfway through an answer he rapidly flexed my swollen knee, almost sending me off the table. Once I had stopped hyperventilating, he did it again to show my parents. My philosophy toward physical exam has been influenced by that experience.

For a gentler exam:

  • Move slowly and get the athlete to relax.
  • Examine the unaffected side to gain trust and to give a comparison examination. This is important in young athletes who already have a certain and variable amount of normal laxity.
  • Encourage the patient to demonstrate active range of motion before forcing passive motion.

We can then proceed through the physical examination using the above principles:

  • Look for bruising, swelling or evidence of deformity.
  • Gently at first, then more firmly, feel for swelling, crepitation or grinding.
  • Test range of motion, first actively and then passively.
  • Test strength, beginning with resistance to gravity and progressing in intensity.
  • Test for instability. Multiple tests are available, depending on the joint. The important thing is to assess symmetry.

The history and physical exam may require further diagnostic testing. Rarely, if ever, should plain X-rays be bypassed solely in favor of MRI or some other advanced test. Evaluation of growth plates, presence of fractures and bony alignment are all best determined on plain radiographs.

Still, advanced testing can give us a world of information. CT is best for subtle bony fractures and alignment. MRI captures bone bruising and soft-tissue injuries such as torn ligaments and muscle strain.

Treatment to regain full motion, strength

Gentle initiation of treatment often can begin during the wait for results of advanced testing. The acronym RICE – rest, ice, compression and elevation – can be instituted quite quickly. If we have ruled out fracture or other injury that might require mobilization, it’s important that the rest phase is considered “active rest,” during which the athlete is working to restore range of motion and initial muscle activation. The recommendation to “put the knee in an immobilizer and follow up in two weeks” is rarely in the athlete’s best interest.

Early and judicious use of physical therapy may help speed a return to activity. Therapeutic modalities for pain and swelling can be helpful, as well as a skilled physical therapist, who can evaluate areas of weakness and imbalance.

The decision to return an athlete to competition is challenging and sometimes formidable. For me, the athlete must be able to exhibit full range of motion, full strength and be able to practice at full speed before being cleared to play. Anything less will potentially put the athlete in harm’s way.

There are some shades of gray as we look at some of our elite athletes, or high school seniors pushing for a scholarship or the prospect of a final tournament. I recommend involving a musculoskeletal expert when those very challenging circumstances arise.

Careful use of our most fundamental medical skills, judicious use of advanced imaging techniques, and a strong ethical philosophy of keeping the athlete safe for long-term competition will ensure that we’re providing the highest-quality medical care to our young athletes.

To learn more or to refer a patient, visit Providence Orthopedic Institute.