The Fortius Clinic Lecture Series - July 2015 Issue

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In this issue:

Lisfranc Injuries in Kitesurfing & Windsurfing

Mr Nick Savva

Swimmers Shoulder Injuries Mr Ali Narvani

Watersport Injuries of the Wrist

Mr David Hargreaves

WATERSPORTS

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Kitesurfing, Skimboarding and Surfing were the main focus from Foot & Ankle Consultant Nick Savva . He explained that despite injuries in watersport athletes becoming more common, they can often be shrugged off and dismissed. From this he concluded that to get the best results, early diagnosis and treatment is key.

Ali Narvani, Consultant Shoulder Surgeon, followed with a talk focusing on Swimmers and a detailed explanation about how incorrect technique can lead to shoulder pain, given that the average competitive swimmer performs 30,000 shoulder rotations each week! This amount of duration and intensity correlates to an injury called supraspinatus tendinopathy. Although shoulder pain is extremely common in swimmers, the best treatment is mainly non-operative.

Never a dull moment with Hand, Wrist & Elbow Consultant David Hargreaves. He amused the audience as always with his lively and interactive talk. He discovered a new sport ‘Underwater Rugby’ which has apparently changed his perspective on the cause and treatment of ‘Hook of Hamate’, a common injury which can be treated in various ways, but most commonly by non-op immobilisation. He compared common injuries across sports ‘in the water’ and ‘on the water’ such as diving vs. rowing, with a focus

on thumbs, fingers and wrists.

The next lecture evening will take place in September; this will have a theme of Football Crazy. We hope to see you all there and enjoy the rest of the summer!

The Fortius Lecture EveningEvery month the Fortius Clinic hosts a lecture evening for physiotherapists and Sports & Exercise Medicine professionals, led by a different team of specialists. The evening event is held in central London. If you would like to be added to our invitation list, please email RSVP@ fortiusclinic.com.]

Meghan Williams, Business Development Executive

e: meghan.williams@fortiusclinic.com t: 0203 195 2445.

JULY TOPIC:

WATERSPORTS

This month’s lecture was the first that we’ve dedicated to Watersports, so generated a good level of interest. Despite the time of year, when many of you are away basking in the sunshine, quite a few of our regulars attended, resulting in another good turnout. Feedback was positive all round with some great tweets and appreciative comments on the ‘excellent content’ and ‘informative and insightful talks’.

Don’t forget to follow us on Twitter @FortiusClinicUK.

You will also find us on Facebook and LinkedIn.

Fortius Clinic Imaging Department is open on a Saturday for MRI, Ultrasound and X-ray.

Musculoskeletal Imaging Examinations

Now available on Saturdays• Same Day Appointments• Rapid Radiology Reports

Monday - Friday 8am - 8pmSaturday 8am - 1pm

Call 0203 195 2446 or email imaging@fortiusclinic.com

Join in our September Social Media quiz for the chance to win our mystery prize!

For more information please visit the FISIC website: www.fisic.co.uk or call Harriet Webb on 0203 195 2434 (harriet.webb@fortiusclinic.com)

On October 13th and 14th we are holding the Fortius International Sports Injury Conference at the Queen Elizabeth II Conference Centre, central London. The physio and SEM programme highlights include sessions on bone health, concussion, disability sport, muscle injuries, return to play, the future of cell therapies and the adolescent athlete, as well as sessions specific to all sub-specialities.

Videos and Newsletters available online! www.fortiusclinic.com

> news-events > lecture-series

12 CPD have been awarded for this 2 day conference by the RCP.

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FEATURE | Lisfranc injuries in Watersports Lecture by Mr Nick Savva

Consultant Orthopaedic Foot and Ankle Surgeon

The most common problems encountered when on the water are sunburn, dehydration, cuts and bruises. Virtually every possible musculoskeletal injury has been reported during kite and windsurfing but I am going to focus on the lesser known, and potentially serious, Lisfranc injury. These are being recognised with increasing frequency in sports where the foot is attached to a board with a foot strap across the mid-foot.

Lisfranc was a surgeon from the Napoleonic era who first observed this injury of the foot in horse riders. A rider dismounted in battle can be dragged by a foot caught in a stirrup causing a fracture dislocation through the tarso-metatarsal articulation.

The Lisfranc joint is between the tarsal and the metatarsal bones is a very important structure for maintaining foot shape and function. The shape of these bones forms a Roman arch with the second metatarsal as a keystone recessed into the cuneiforms. The alignment of the metatarsals with the cuneiforms and cuboid is very regular and relatively easy to assess on plain radiographs.

Road traffic accidents and falls from a height are the most common cause of high energy fracture dislocations these days. These are relatively easy to diagnose and commonly associated with polytrauma. The majority require surgery to restore anatomy.

More subtle sprains can occur to the ligamentous complex of this joint during sport if the foot is overloaded during a rotatory movement. It is easy to imagine how this might occur landing awkwardly from a jump on a wind or kite surfing board. We are getting better at spotting these injuries so they are now more frequently treated.

Instability of the Lisfranc joint may eventually result in degenerative arthritis and so identification and treatment are very important. A detailed history and examination are the most important at identifying potential injuries. Presentation often includes bruising on the sole of the foot. The patient complains of a painful mid foot and sensations of instability. In severe cases the longitudinal and transverse arches collapse on weight bearing. It is useful to compare sides but beware the bilateral injury!. Weight bearing X-rays usually reveal malalignment between the metatarsals and cuneiforms. It is sometimes useful to image the normal side for comparison.

Occasionally stressing the foot in theatre is the only way to identify subluxing joints or an avulsion fracture of the Lisfranc ligament. CT and MRI scans can be very useful to identify more subtle injuries and sprains.

Grade 1 injuries are essentially sprains, with no deformity. The ligaments are intact but there is bruising on the base of the foot which is painful to stand on.

Grade 2 injuries involve up to 5mm of diastasis between 1st and 2nd rays due to a partial or complete rupture of the Lisfranc ligament.

Grade 3 is when the diastasis is greater than 5mm and loss of the foot arches develops.

The treatment of grade 1 injuries is rest in a stiff boot for a few weeks. An orthotic arch support will probably aid a return to sport between 6 weeks and three months.

Treating Grade 2 and 3 injuries is more controversial. Percutaneous screws can be used to reduce the

displacement. This however does have the disadvantage that relatively uninjured points are breached by a screw which may result in degenerative changes in the long term. An alternative strategy is to hold the joints reduced with plates. This has the advantage that the joints are not damaged by screws but it does require open surgery. Regardless these constructs are extremely stiff and are usually removed after a few months routinely. Currently flexible fixation such as the tight rope is being assess for its efficacy at holding these injuries reduced. There is the theoretical advantage that a secondary removal operation is not necessary but the jury is still out. Primary fusion of the Lisfranc articulation is considered for severe injuries where the joints are very badly damaged.

Delay in treatment worsens the prognosis of all grades of injury. The most important issue is to raise our index of suspicion for these injuries.

Mr Nick Savva Consultant Foot and Ankle SurgeonConsultant Orthopaedic Surgeon specialising in foot and ankle injuries, arthroscopy, bunions and lesser toe deformities.

“Lisfranc Injuries result from a twisting movement on a loaded

forefoot.”

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One condition can lead on to another, and even another, so it is very important to isolate and treat the primary condition. Physiotherapy is the most effective treatment. Surgery is the last resort. Only in rare cases will surgical arthroscopic subacromial decompression be necessary for impingements.

A competitive swimmer swims between 60,000 and 80,000m per week, which means approximately 80,000 rotations. That represents a huge stress on the shoulders which can result in repetitive micro-trauma. Damage to the tendons and cells can lead to tendinopathy and impingement. Comparing the numbers of hours swum to the frequency of supraspinatus tendinopathy indicates a strong correlation between the amount of training and the amount of injury.

Freestyle, the stroke with most shoulder issues, has

three distinct phases: hand entry; pull-through; hand exit and recovery. 70% of symptoms are felt in the first half of the pull-through, as the athlete is generating a lot of force to pull the body over the water. The scapula is protracted, the humerus is adducted, extended and internally rotated. As the muscles fatigue, the swimmer feels pain. Also, if the muscles stabilizing the scapula are not working efficiently, the scapula will not move efficiently, causing secondary impingement.

Faulty technique is often the cause. During the pull-through, the elbow should be much higher than the wrist. If the elbow is lower, the muscles are lengthened, are not at their optimal contraction length and fatigue earlier. Again, if there is a dropped elbow in the recovery phase, this causes an upward force on the humerus which can result in secondary impingement.

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FEATURE | Swimmers Shoulder Injuries

Up to 87% of competitive swimmers, according to recent papers, suffer from a disabling shoulder pain at some stage. In most cases, this is supraspinatus, tendinopathy and impingement. But there can also be bicep abnormalities, rotator cuff tears, labral tears, os acromiale, ACJ pain and arthritis.

The head should be in the water during the pull-through. If the swimmer is looking forward instead, the muscles extending the neck will prevent the scapula from moving normally, which can lead to secondary impingement. The hand should enter the water somewhere between the shoulder and head with all the fingers entering together. If the thumb leads, this will rotate the forearm producing excessive force on the long head of the bicep where it attaches to the superior labrum, potentially causing damage.

Swimmers and throwers often have a lax anterior capsule and so mild anterior hyperlaxity can lead to secondary impingement.

Many competitive swimmers use paddles to increase their resistance. Paddles mean additional forces on the structure of the shoulder, therefore increasing the likelihood of injury. Most swimmers have increased thoracic kyphosis and hyperlordosis of the lower back, so as a result of the reduced subacromical space, there can be secondary impingement and scapular dyskinesia.

Surprisingly, errors in technique are very common in competitive swimmers, who also believe that pain is inevitable in elite sport, so do not address it.

Prevention is key. This means recognising and correcting faulty technique, in addition to programmes of stretching, strengthening, endurance training, core muscle exercises and careful monitoring. When the shoulder is injured, training volume and intensity should be adjusted to enable recovery. Rest, reduced training, ice packs, technique correction, exercises for core and scapula stability and to tackle a tight posterior-inferior capsule will all help.

Physiotherapy will correct posture and will encourage general strengthening and balance work. It will address issues such as a tight anterior chest wall, a hypermobile thoracic spine, excessive joint mobility or a tight posterior-anterior capsule. This should greatly help patients who get pain only at the time of swimming. For those who get pain even when they are not swimming, in addition to the treatment above, they should have a longer period of rest from swimming, take non-steroidal anti-inflammatories and possibly have a single steroid injection. Only then, if the patient has been symptomatic for more than three months,

should surgical decompression for a mechanical primary impingement, or repair to injuries such as labral tears, be considered.

In conclusion, swimmers’ shoulder pain is common and technical error is often the cause. Prevention is the best solution and treatment is mainly non-surgical.

Mr Ali Narvani Consultant Orthopaedic Shoulder SurgeonSpecialising in shoulder and elbow treatment. His primary clinical interest is arthroscopic shoulder and elbow surgery for athletes

Lecture by Mr Ali NarvaniConsultant Orthopaedic Shoulder Surgeon

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FEATURE | Watersport Injuries and the Wrist

As an upper limb surgeon, I often see a diving injury similar to skier’s thumb, when the thumb gets caught and pulled back causing a sudden disruption of the ligament, classically the ulnar collateral ligament. If the joint opens up by more than 60 degrees, the ligaments won’t return to their correct position, resulting in a Stener lesion, so early referral and early surgery is necessary.

Elite divers can suffer scaphoid fractures of the wrist, due to sudden hyperextension. The forced flexion of the elbow as the diver hits the water, while attempting to keep a straight elbow to improve entry position, can result in a triceps rupture. These injuries are otherwise very rare.

Swimmers also have finger injuries when they hit a rope and the finger gets caught and pulled out, potentially causing a collateral ligament injury. But the hand normally has a lot of movement with the fingers in extension, so to diagnose a radial collateral ligament injury, you need to bend the fingers to 90 degrees so that the collateral ligaments are tight, and there should then be no lateral or ulnar movement of the fingers.

A new sport, underwater rugby, a 3D version of water polo, is producing hook of hamate fractures. Up to now, we have associated these fractures with falls over the handlebars of a bike, landing on the hand, or a stress injury from the handle of a golf club or tennis racket. However, the fact that underwater rugby players experience them, without a fall or racket head issue, has made me realize, using the right test, that many

are not caused by an impact, but instead from the pull of the flexor digitorum profundis muscle (FDP). We need to stop these athletes bending their little fingers, so immobilizing them in radial deviation, and possibly strapping their fingers, may cure it. If there is still a non-union, the hook of hamate can be excised surgically, which sounds drastic but is very successful. However, the other surgical option is to put a screw down this tiny bone, which I think is nonsense!

Boating injuries include crushed fingers, and if there is a bit of nail sticking out, this needs immediate referral for it to be surgically put back in – this is not a physiotherapy issue. Obviously falls are common, and so biceps tendons can be ruptured. Sudden ulnar deviations of a finger or an avulsion can occur. If an avulsion happens on a ring finger, the ring must be taken off immediately.

A number of canoeists suffer from pain in and around the ulnar collateral ligament, which is otherwise a rare complaint. The canoeists report no single injury but the condition is preventing them from paddling. On exploring further, I discovered that back-pedalling, when trying to reverse or turn the canoe, is the most problematic movement. This involves significant force from the paddle and the canoeists have therefore developed a version of gamekeeper’s thumb, where the ulnar collateral ligament has been stretched slowly over time. Rest from the sport, a thermoplastic splint and maintaining good posture over three to four months will all aid recovery. A splint or support is advised when they return to canoeing.

Lecture by David Hargreaves Consultant Orthopaedic Hand and Wrist Surgeon

When you dive into a pool, from just one metre, you are hitting the water at about 20 miles an hour, so the impact is considerable. It’s therefore unsurprising that those who dive from 10 metre boards have, almost without exception, sustained some injury in training or competition. The repetitive trauma from hitting the water is not dissimilar to those found in gymnasts, who from a young age are learning to tumble and sustaining repetitive problems which can damage the physeal part of the bone. for about a quarter of all musculoskeletal injuries. The inversion injury is the nearest thing to tennis ankle.

Mr David Hargreaves Orthopaedic Hand and Wrist Surgeon

Consultant Orthopaedic Surgeon treating a wide range of degenerative and traumatic conditions of the hand and wrist, with special interest in arthroscopic surgery.

Rowers often suffer from intersection syndrome in the forearm. The area becomes inflamed because there is rubbing of the thumb extensors over the wrist extensors. Rest, avoiding rowing, ice in the early stage and a splint should all correct this. If not, a steroid injection may help and very rarely surgery is necessary to release the fascial bands between the two muscles at the site. This condition, similar to de Quervain tenosynovitis, but occurring slightly more proximally, is also found in other sports such as badminton.

Occasionally someone suffering from intersection syndrome experiences a sudden tearing sensation with bruising at the site. Strangely, this often cures

the problem, because what has happened is that some fibrous tissue tethering the two groups of muscles together tears, thus relieving the symptoms!

Finally, water-skiers particularly suffer from exertional compartment syndrome, which also affects windsurfers and tennis players. A less common water-skiing injury is when they fall and the rope gets wrapped around their arm, resulting in biceps muscle injuries. But for all these water sports injuries, taking a good history, being aware of the various conditions and being precise about the site of maximal pain are the crux of making the correct diagnosis.

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Lectures by:

Mr Andy WilliamsConsultant Foot & Ankle Surgeon

Dr Mark Wotherspoon Sports Physician

For further information or to book an appointment, please contact us:

t: +44 (0) 203 195 2442 f: 0203 070 0106 e: appointments@fortiusclinic.comw: www.fortiusclinic.com

Don’t forget to follow us on Twitter @FortiusClinicUK.

You will also find us on Facebook and LinkedIn

How to find us:Fortius Clinic is situated in Central London, close to Selfridges, and just off Manchester Square.

17 Fitzhardinge Street London W1H 6EQ

To be added to the attendance list please email: RSVP@fortiusclinic.com

September lecture: Football Crazy

DR Richard Weiler Sports Physician

14th September