Sport related pathologies

Athletes are not regular patients, both for their exceptional performances in sports and because if, and when, they become victims of trauma, they may be affected not only physically like the rest of us, but also personally and professionally. However, it should be noted that sometimes having some rest would be enough for them to reduce or solve their sporting injury problems without the need to go to an orthopaedist.

When such special patients come to me, it is usually because they have a pressing need to reduce recovery time or to move a little beyond the bar of their physical limits. To help them in this apparently superhuman endeavour, I follow the first incontrovertible principle of the Fathers of medicine (“Primum non nocere“) and I am inspired by the innovation and by a constant work of professional training and updating. In this way I can help my “special” patients to push their limits a little further, but obviously, always respecting both the law and professional ethics.

To sum up the vastness of physical problems that can affect the world of a sportsman, I will list below some keywords of sport pathologies, first of all giving some advice of common sense and not only on how to prevent certain injuries.

 Sports injury prevention

When talking about foot and ankle injuries, prevention means, first of all, choosing proper footwear for your needs but also to study the posture of the foot both when static and when in motion.

Those who in recent years have been practicing the now-so-popular marathon or running (but it also applies to the long or middle-distance running in athletics) may have noticed that a lot of websites, more or less famous, indulge in giving advice on which shoes you should choose depending on the shape of your foot: pronator, supinator or neutral. The same goes for the many stores specialising in sports clothing and equipment where some salespeople, often naively, feel and act as if they were orthopaedic specialists within the field of sports injuries..

To effectively recommend a specific type of shoe (suitable for pronator or supinator, for example) you need to have studied and understood the entire gait cycle and you need to know how to evaluate the risks of overload that can occur in performing a particular technical gesture. Even a computer analysis of the step can be useless if not associated with a careful clinical evaluation.

Making a correct choice means reducing the risk of overloading and especially of athlete “over use” pathologies: tendinitis, bursitis, but also stress fractures and microfractures.

Making a wrong choice means, in the long run, inducing a pathology. By way of example, we can cite the recent “class action” promoted in the US by the users of minimalist shoes against the manufacturers. Blaming minimalist running shoes a priori for the cause for physical damage is not correct. However, using them indiscriminately without considering the risks or the benefits for the athlete who uses them can definitely be a problem.

This is why I think it is essential to make a clinical evaluation of the patient and the athlete, sometimes associating it with functional instrumental (baropodometry) and/or imaging (weight-bearing X-Ray) examinations and with a careful study of sports movements. To have a better evaluation I suggest bringing a detailed description of the training plan and a video recording of the usual performance of the athlete.

In this regard, I recently made and published, in collaboration with The Polytechnic University of Milan and the University of Liverpool, a study on rugby shoes and on the different stresses the foot is subjected to, depending on the player’s role.

Obviously, footwear, even the cutting edge ones, are always a serial, not unique product and may not be sufficient to meet the unique needs of each athlete. For this reason, orthotics can be useful, not as a simple support to the arch, but as special instruments to be studied and designed case by case depending on the athlete’s specific technical movements.

Finally, you need to observe that the shear forces (i.e. friction) may be an important tiring factor. For this, nowadays there are different types of neutral and very thin orthotics that have no function of biomechanical compensation, if not reducing friction. Again, an indiscriminate use of these supports can not only be useless but also harmful, so it is always necessary to rely on competent people who can suggest their use.

Muscles and tendons

The muscle, for its contractile capacity and the tendon, for its elastic capacity, are likely to experience breakage/damage (tear and stretch) or overload pathologies (tendinosis and tendinitis).

Acute injury (tear/stretch)

When in the presence of this type of injury, it is a misconception that immobilisation and rest alone can lead to healing in satisfying time. Instead, if there is a reasonable doubt of being in the presence of a muscle or myotendinous injury, it is important to perform a prompt diagnosis, with a simple ultrasound examination, and obtain information on the location and the extent of the lesion.

When diagnosing muscle injury, there is little or no space for surgery; however, contemporary biology is of great help. Indeed, you can use the PRP (or growth factors) to stimulate processes of self-healing. Combining it with a plan that includes the proper use of innovative physical therapies (Tecar Therapy InterX®, Cheltherapy) can make the difference in ensuring a fast recovery and reduce any possible after effects.

In the case of acute tendon injury, it may be necessary to use surgery, however, paying attention to reconcile two important aspects: reduced invasiveness and stability of the repair. Once again, the PRP will accelerate everything.

Chronic or acute injuries that eventually become chronic (tendinitis, tendinosis, fibrosis, tendinopathy)

Chronic injuries may be the result of an acute injury that produces scars and fibrosis or simply becomes chronic. Further cause of a chronic injury can be an incorrect technical movement or the wrong choice of footwear. In these cases, prevention has failed and you should be working on that.

Also in this case, as already said for acute injury, the PRP and multipotent cells taken from adipose tissue make the difference in terms of recovery times and effectiveness.

To mention the other strings to the bow of a good orthopaedist in charge of the care of an athlete, then there are all the innovative physical therapies (Tecar Therapy, InterX® and Cheltherapy) associated with modern techniques of physiotherapy (fibrolysis, pompage, osteopathy, chiropractic, kinesio taping). A delicate task for the doctor will be to customise, case by case, the therapeutic procedure, dictating the times.

Ligaments: instability

Ankle

The well known “ankle sprains” can lead to ligament injuries, which are not always of surgical interest.

These traumas can especially affect basketball, volleyball, football, rugby players, but also ordinary people with or without the habit of regular physical activity.

The ankle ligaments, contrary to those of the knee area, are mostly non-articular. The knee ligaments are like the spokes of a bike, that is, they are intra-articular and contribute significantly to the structure’s stability. In the ankle these spokes are outside of the structure. This will increase the exposure to injury but, at the same time, impact less on the ankle’s stability.

I often receive patients who are worried about the result of a resonance that shows completely damaged ligaments. Actually, as I explain to them, the ankle ligaments are more easily subject to sport injuries than those of other joints, but more often they heal after a fibrous scar that returns the original ligaments stability.

In these cases, a re-education through physical therapies and physiotherapy (Tecar therapy, kinesio taping, fisiokinesitherapy) is fundamental for the articulation’s recovery. And then a proprioceptive rehabilitation to accustom the ankle to the change of direction and to the unevenness of the ground, using special boards and customized exercises.

Only in 15-20% of the cases a ligament injury causes chronic instability, that is the tendency of the ankle to yield. It is in this situations that surgical intervention will becomes necessary. Today, there are minimal invasive operation techniques available, not only with the aim to restore the ankle stability, but also to prevent any possible recurrence of sprains and concomitant cartilage lesions.

The Foot

The sprains can also affect the mid foot area, resulting in the so-called Lisfranc injury. The name comes from one of Napoleon’s field doctors, who defined a technique to perform the amputation of severely damaged feet of the soldiers injured along a well-defined area: the one that connects the mid foot (metatarsals) and the hind foot.

Leaving aside brave Napoleonic soldiers, the rugby and American football players are the warriors of our time who, more than others, risk injury in this area of the foot. The spectacular and dangerous dives of a defender on the foot of an opponent who is running for try are generally the main cause of these injuries.

Paradoxically, this type of sports injury are common to rugby players and a category of athletes with a completely different temperament and a way more obvious grace: dancers. The “en-pointe” position (a daily way of life for these artists) can cause ligament injuries, but also bone injuries, stressing this anatomical region.

These sports injuries have a much slower and more insidious progress than ankle sprains and may require stabilisation operations more frequently, as I explain in a study published during my work experience at Duke University (Lisfranc injuries in sports).

The posteromedial impingement of the flexor hallucis longus in ballerinas

It is a real professional pathology.

For a surgeon with my specialization in foot and ankle sports injuries, to cure what is the existential core of these exceptional dancers is a therapeutic challenge that can be difficult, yet rewarding. I guess it is also the same for my colleagues specialising in hand injuries when they take care of a pianist or a violinist.

In classical ballet, shoe solicitation and the “en pointe” position can cause an anatomical modification at the level of the talus (the hind foot bone that articulates with the ankle). This anatomical alteration consists of a fibrous thickening of the posterior-medial margin of the talus, which leads to a conflict (i.e. irritating it when it is sliding) with the flexor hallucis longus tendon.

The patient usually complains of difficulty keeping the “en pointe” position, endures calf cramps and pain in the ankle, exacerbated by the bending of the big toe.

At first you can suggest a non-invasive solution recommending rest and prescribing an appropriate physical therapy (Tecar Therapy). If the conservative approach seems insufficient or ineffective, you can switch to surgery. In these cases it is necessary to resort to a posteromedial lysis with removal of the cause of the conflict (os trigonum) and of fibrous thickening. In most cases this operation can be done in a arthroscopy, a technique that allows to minimize the invasiveness (requires posterior arthroscopic portals) and, above all, the recovery time. Each individual case needs to be assessed with the possibility to choose this technique instead of the more traditional one, and then determine the timing for the return to the stage.

Bones: stress fractures

The fracture of a bone is not always related to an acute injury. In fact, small but continuous and repeated trauma can cause stress fractures. The athletes who are most exposed to these risks are undoubtedly marathon runners.

The typical stress fractures most frequently encountered in this sport affects the metatarsals and are favoured by a particular length of the latter (in the case of the second and third) or by a pes cavus (in the case of the fifth metatarsal).

It is rarely necessary to perform surgery to heal these problems. Appropriate physical therapies and the use of growth factors (PRP and multipotent stromal cells of fat) will be much more efficient.

Obviously, all this must be guided and supervised by an experienced foot surgeon who is not only able to trace the more correct therapeutic procedure but also to accurately assess the technical movement of the athlete and suggest the use of proper footwear that reduces the risk of recurrence of the problem.

The scaphoid is another bone, which is commonly susceptible to stress fractures. In these cases, minimally invasive surgery with percutaneous synthesis often turns out more satisfying than classic surgical approaches, also facilitating fast recovery. Also in this case, the choice of a specialised professional is recommended.

Finally, I quote the ballerinas as highly susceptible subjects to stress fractures at the level of the base of the second metatarsal; once again the cause is the “en pointe” position. 

Cartilage

PRP AND THE MULTIPOTENT CELLS OF THE STROMAL FRACTION OF ADIPOSE TISSUE

Several times they have been cited in the discussion above and so it is necessary to briefly outline the amazing regenerative capacity of PRP and multipotent cells.

In our blood there are platelet-derived growth factors capable of inducing tissue repair and regeneration. A simple blood test of the patient is needed, subjecting it to centrifugation and then proceed to the extraction of the growth factors. After this operation is done with a simple injection, reintegration is possible in the human body in the injured anatomical area.

Obviously it is not a panacea from which to expect miraculous healings but it is definitely one more available tool to competent and responsible doctors who can use it for the benefit of most effective and fast treatment, both for athletes and for all the other patients.

Also it is a very recent discovery of the enormous regenerative power of the so-called multipotent cells of the stromal fraction of adipose tissue that are present indeed in the human adipose tissue (fat). Once removed from the source, they can differentiate and give rise to proliferative and reparative phenomena of the tissue in which are then injected and housed.

The hypothesised increased efficacy is linked to the fact that the PRP convey some messengers of regeneration for the local cells, multipotent stromal cells would enrich the local cell heritage in addition to bringing the messengers of regeneration.

The taking of sample is done under  local anaesthesia. A particular needle will draw a small amount of adipose tissue, which is then filtered to isolate multipotent stromal cells; these will then be injected into the injured area to be treated.

These two processes are apparently very similar and there is now no scientific evidence in favour of either of them. Both are safe procedures, with a great therapeutic potential.

I am currently in charge of a prospective scientific study supported by IRCCS Galeazzi that, for the first time, compares the effectiveness of the two methods in the pathology of the Achilles tendon. The preliminary results are encouraging.