Exercises and physiotherapy can help rehabilitate minor sports injuries, but severe sports injuries require a visit to the doctor.

Sports injury types:

Different sports injuries result in various symptoms and effects. The most common types of sports injuries consist of:

• Sprains: They are caused by overstretching or tearing of the ligaments. Ligaments are strands of connective tissue that hold two bones together at a joint.
• Strains: It occurs when muscles or tendons are overstretched or torn. Tendons, which connect bone to muscle, are substantial, fibrous strands of tissue. Sprains and strains are frequently confused.
• Muscle swelling: It is a typical response to an injury. Muscles that are swollen may also hurt and feel weaker.
• Fractures:
• Dislocations: Bones in your body might dislocate/ yanked out of its socket. Swelling and weakening may result from this, which can be uncomfortable.
• Knee injuries: Any injury that restricts the knee joint’s motion may qualify as a sports injury. It may be anything from an overstretch to a tear in the knee’s ligaments,menisci or muscles.
• Rotator cuff injury: The rotator cuff is made up of four separate muscles. Your shoulder may move in any direction thanks to the rotator cuff. The rotator cuff can become weak if one of these muscles’ tears.
• Achilles tendon rupture: At the rear of your ankle, the Achilles tendon is a strong, thin tendon. This tendon may rupture or break when playing sports. When it does, you could feel sharp, excruciating pain and have trouble walking.

It is advised that you speak with a qualified pain management specialist to go through your treatment choices if you have any of the above injuries or symptoms. To get timely treatment, it’s crucial to schedule a consultation with a pain management specialist for evaluation and diagnosis.

Sports-related injuries are common, and effective pain management and treatment are crucial for athletes to recover and get back to their activities.

Here’s a basic guide to sports pain management, injuries, and treatment:

• R.I.C.E. method: For acute injuries like sprains, strains, or contusions, the R.I.C.E. the method can help with pain management and initial treatment. R.I.C.E. stands for Rest, Ice, Compression, and Elevation. Rest the injured area, apply ice packs for 15-20 minutes at a time, use compression bandages to reduce swelling, and elevate the injured limb above heart level when possible.
• Over-the-counter pain relievers: can help manage pain, reduce inflammation, and relieve swelling. Follow the recommended dosage and consult a healthcare professional if you have any concerns or if you need stronger pain medications.
• Physical therapy: For more severe injuries or as part of the recovery process, physical therapy can be beneficial. A qualified physical therapist can guide you through exercises, stretches, and rehabilitation techniques to strengthen the injured area, improve mobility, and reduce pain.
• Injury-specific treatments:

• Sprains and strains: Depending on the severity, sprains and strains may require immobilization with braces, casts, or splints. Physical therapy can aid in restoring function and flexibility. Injections such as steroids or PRP may also be considered.
• Fractures: Broken bones may require casting, splinting, or even surgery in some cases. Follow your healthcare professional’s guidance for immobilization, weight-bearing restrictions, and rehabilitation.
• Tendinitis: Rest, ice, and avoiding activities that exacerbate the pain are the initial steps for managing tendinitis. Physical therapy, stretching, and strengthening exercises can help alleviate symptoms and prevent recurrence. Injections such as steroids or PRP may also be considered.

• Injury prevention: Proper warm-up and cool-down exercises, stretching routines, wearing appropriate protective gear, maintaining good technique, and gradually increasing training intensity can help reduce the risk of sports-related injuries.
• Professional medical advice: If you experience severe pain, persistent symptoms, or suspect a serious injury, it’s important to consult a healthcare professional, such as a pain specialist or sports medicine physician. They can provide an accurate diagnosis, recommend appropriate treatment, and create a tailored rehabilitation plan.

Final words from Dr. Amod Manocha

Sports and exercise are crucial for maintaining good health, yet they frequently result in accidents. Many minor sports injuries that are anticipated can be managed at home with rest and other techniques.

If swelling, discomfort, and bruising don’t go away or if there is a serious injury, you need to contact a doctor. Additionally, sports injuries happen frequently, despite your best efforts. Dr. Amod Manocha, the best pain management specialist in Delhi and Gurgaon, offers a one-stop solution with top-notch technology, ensuring the best care and a quick recovery.

CONNECT TO DISCONNECT FROM PAIN!

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Piriformis muscle is located deep in the buttock and helps to rotate the leg outwards. It extends from the side of sacrum and tailbone to the upper part of thigh bone. One of the main nerves of the leg (sciatic nerve) runs in close relation to this muscle. Problems of the piriformis muscle such as spasms or swelling, can cause irritation of the sciatic nerve leading to sciatica like symptoms. This condition is addressed as piriformis syndrome (PS). Other names for this condition include extra-spinal sciatica, deep gluteal syndrome or wallet neuritis.

What are the symptoms of piriformis syndrome?

Most patients present with buttock and leg pain which is worse on sitting and with hip movements. Pain is described as a dull ache, shooting or burning sensation associated with buttock tenderness. Most patients sit with the affected side tilted upwards. Some patients complain of a swelling, sausage shaped lump sensation in the buttock. Pain commonly radiates towards hip or down the back of the thigh, leg. Walking upstairs or on inclines can increase pain, with relief on lying down. Sometimes when pain is severe it may cause individuals to limp while walking. In females there may be pain during sexual intercourse (dyspareunia).

What causes piriformis syndrome?

PS is six times more common in women and middle ages. Individuals sitting for prolonged periods (long-distance bikers, office workers) and occupations such as truck & taxi drivers, tennis players are at a higher risk. Variations in the anatomy of piriformis muscle, sciatic nerve or its path can predispose to the irritation of the nerve. In majority of individuals the nerve travels below the muscle, it may however travel through or over the muscle or may be split into two. Other causes of piriformis syndrome include

• Trauma or Injury to the muscle such as after a fall onto the buttock, surgery or lumbar and sacroiliac joint pathologies.
• Overuse and microtrauma such as during intense downhill or long-distance running/walking. This can cause muscle spasm and shortening.
• Direct compression as during sitting on hard surfaces may cause repetitive trauma
• Compression due to direct pressure from a tumour invasion, or abnormal dilatation of a nearby blood vessel (inferior gluteal artery aneurysm)
• Post-radiotherapy fatty atrophy of the piriformis muscle
• Altered leg, back or pelvis biomechanics

How is piriformis syndrome diagnosed?

The commonest cause of sciatica is the irritation of the nerves in or near the spine. PS represents an extra spinal cause where the site of nerve irritation lies outside the spine although the symptoms are similar. Correct diagnosis helps to offer targeted treatment and increases the probability of a successful outcome. Another nearby muscle (obturator internus) can cause similar symptoms and this needs to be differentiated from the PS.

Diagnosis begins with a comprehensive history and physical examination. An MRI is useful for detailed evaluation of the lumbar spine & pelvis and ruling out other conditions with similar presentation. X-rays can be used for the evaluation of neighbouring bony structures such as the hip and sacroiliac joints. Electromyography (EMG) may help in differentiating PS from pain originating from the spine.

A local injection into the piriformis muscle is often used to confirm the diagnosis. This is discussed in the treatments section.

What are the treatment options for piriformis syndrome?

Treatment involves a combination of the following;

• Short term rest and activity modification
• Lifestyle modification
• Physical therapy including stretching exercises of the piriformis, hamstring muscle and strengthening of the abductor and adductor muscles
• Medications including anti-inflammatories, muscle relaxants, neuropathic medications (ones used for nerve pain).

If these measures fail to resolve symptoms, then the next step is injections.

Ultrasound Guided Injections

Steroid injections are the most commonly used injection option. As stated previously injections can not only provide relief, but also help in confirming the diagnosis. Using ultrasound helps to improve accuracy and reduce chances of complications. X-rays guidance is an alternative, although ultrasound is preferred as it can be performed in outpatient settings and offers other advantages such as visualisation the piriformis muscle, blood vessels and the sciatic nerve. Local anaesthetic and steroid mixture is used for the injection. Local anaesthetics help to relax the muscle and steroids aid in reducing inflammation thus prolonging the effect of the injection.

Botox injections work by paralysing and relaxing the piriformis muscle, thereby taking the pressure off the sciatic nerve. The effect of these injections can last for a few months proving an opportunity to address the root cause and engage in physical therapy.

Surgery may be considered for severe cases not responding to other measures. It involves either cutting the piriformis tendon from its hip attachment or cutting through the piriformis muscle to take pressure off the sciatic nerve.

Return to sports and activities varies between individuals and depend on the time taken in reduction of the symptoms. Too early a return has the potential to cause worsening of injury and reoccurrence of the symptoms.

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What is acromioclavicular joint and where is it located?

The acromioclavicular (ACJ) is a small joint between the collarbone (clavicle) and the tip of the shoulder blade (acromion). It is located at the tip of the shoulder forming the highest point of the shoulder. Like many other joints in the body, it has cartilage covering the ends of the bone, is surrounded by a capsule and stabilised by strong ligaments. This joint has minimal mobility. It is involved in overhead arm movement and when the arm is moved across the body.

Arthritis of this joint is more common than that of the shoulder joint (glenohumeral joint) although is less common than that of the hip and the knee joints. It is mostly seen in the middle-aged people and weightlifters and hence the other name of the condition “Weightlifter’s Shoulder”.

What are the symptoms of ACJ arthritis?

Common presenting features include:

• Pain over the top of the shoulder
• Difficulty reaching the arm across the body as while putting on a seat belt or swinging a golf club.
• Pain with overhead movements and when trying to reach behind the back
• Pain after high-intensity activities such as tennis, weightlifting, exercises such as bench press or push up
• Pain when lying of the affected shoulder
• Pain on pressing on the top of the shoulder
• Pain can spread to the rest of the shoulder, neck and front of the chest
• Stiffness associated with inactivity
• Small bump or swelling at the top of shoulder
• Clicking, popping or crunching sensation from the affected joint

What are the causes of ACJ pain?

The common causes include

• ACJ arthritis
• Repetitive strain and chronic injury
• Trauma, sports injuries
• ACJ separation

Problems with this joint are seen in both, young and the aged. In young individuals the joint is involved secondary to injuries/falls or as a consequence of repeated minor injuries due to heavy lifting gym activities. Collision sports such as rugby, throwing sports such as shot put, weightlifting and falls from bike are known to cause ACJ problems.

In older individuals main reason of this joint involvement is arthritis resulting from wear and tear of the cartilage present at the end of the bones. Over time the bones pointed edges called osteophytes can form at the end of the bones. These osteophytes can irritate the neighbouring tendons adding to the pain experienced. The joint space may become narrow or even disappears in advanced stages.

Injuries can cause tearing of the ligaments and disturb the alignment of the bones resulting in joint deformities. This can be quite painful and may require arm immobilization for some time.

How is this ACJ arthritis diagnosed?

The diagnosis can be established clinically on the basis of history and examination findings. Imaging modalities are used in combination with these to confirm the clinical diagnosis. Commonly used modalities include

• X-rays. This may show that the bones are closer together than normal or bone changes such as osteophytes.
• MRI. This can help visualise other tissues such as ligaments, tendons, and muscles in detail. ACJ may show abnormal swelling or excess fluid in or around the joint.
• US scan. This has the advantage of being a quick investigation that can be performed in the clinic and may show changes in the capsule of the joint itself.
• Often an injection of the joint is used to confirm the source of pain as not everyone with arthritic changes has pain.

What are the treatment options for ACJ pain?

Treatment for ACJ arthritis pain requires a multimodal approach using a combination of activity modification, physical therapy, hot or cold compression, medication and injections, if required. Weight lifting, golfing, and exercises involving cross-body arm movement should be avoided. At times only reducing the intensity of the activity may be sufficient rather that giving it up completely.

Simple painkillers like paracetamol, anti-inflammatory drugs and local gels are commonly used for this condition. Anti- inflammatory medications should only be used on clinical advice and for short periods in view of their potential side effects.

Injections. Steroid injections are the most commonly used injections for treatment of moderate to severe ACJ arthritis pain. They can help to confirm the diagnosis and reduce the swelling, pain and stiffness. Using ultrasound guidance helps to improve accuracy, reduce side effects. Some clinicians may also consider PRP (Platelet Rich Plasma) injections although there is not much research regarding their use in this condition.

Surgery may be considered if the symptoms are severe and above modalities fail to provide relief. The most common surgery performed involves resection of a small portion of the end of the collarbone with eventually the scar tissue bridging the gap.

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What is adductor strain?

Adductor muscles are a group of five muscles located in the inner thigh. These muscles help to bring the legs close to each other and stabilise the pelvis during standing and walking.

Strain, injury or imbalance of the adductor muscles is a common cause of inner thigh and groin pain, especially amongst individuals who are physically active or in competitive sports. Soccer players are commonly affected and as per one study adductor strains account for 10% of all injuries in soccer players. Other sports where associated with adductor injuries include hockey, basketball, tennis, figure skating, baseball, horse riding and karate. Tight adductor muscles can lead to hip, knee and back pain and affect our gait. Of all the adductor muscles, one called adductor longus is the one most frequently injured.

What are the symptoms of adductor sprain?

Common presenting features include:

• Groin, inner thigh and lower abdominal pain. In some cases, the pain is intense at the beginning of athletic activity and is later replaced by a dull ache
• Pain on sitting cross legged or when with coughing/ sneezing
• Pain on activity such as

• Lifting one leg as while stepping down from height or getting out of car
• Turning or changing direction
• Walking. In mild cases pain may be provoked by more strenuous activities such as running, kicking or performing lunges 

• Bruising or swelling in the painful area in severe cases
• Localised tenderness in the upper inner thigh, close to where the adductor muscles attach to the pubic bone 

Adductor strains are classified as

• First degree: Pain without loss of strength or range
• Second degree: Pain with loss of strength
• Third degree: Complete disruption of muscle or tendon fibers with loss of strength

What causes adductor strain?

Adductor strains form a significant proportion of groin injuries. In a study among European soccer players, adductor muscle injuries were the second most common (23%) after hamstrings (37%). Risk factors contribution to injury include

• Previous hip or groin injury
• Overuse, fatigue and muscle imbalances
• Weak adductors with poor flexibility
• Poor hip/pelvic stability and strength
• Running on hard surfaces, excessive running
• Footwear
• Training associated factors such as inadequate stretching, and lower levels of sport-specific training changes in training intensity, volume or type of training
• Age- tendons become less able to absorb force as they age
• Biomechanical abnormalities including excessive pronation or leg-length discrepancy
• Genetic factors such as poor collagen

Adductor sprain can be of sudden or gradual onset. Acute injury is associated with sporting actions such as suddenly changing direction at speed, sudden acceleration in sprinting, sliding sideways or kicking. One study analysed the videos of acute adductor injuries in professional male football players and found that majority of injuries occurred in non-contact situations (71%). Common injury actions included change of direction (35%), kicking (29%), reaching (24%) and jumping (12%).

How is this condition diagnosed?

Diagnosis can be usually made clinically. MRI is used for confirming the diagnosis and assessing severity especially in chronic injuries unresponsive to conservative treatment modalities. Ultrasound scan is the alternative imaging option.

MRI Scans can give prognostic information as tears involving >50% of the cross-sectional area, tissue fluid collection, or deep muscle tears indicate more severe injury with prolonged recovery. The location of the tear is important as tears at the junction of the muscle with tendon (musculotendinous junction) can be more aggressively rehabilitated compares to one close to the joining of the tendon with bone, due to differences in the blood supply of the two areas. Tendons can be viewed as ropes tying the muscles to the bones. The musculotendinous junction is the most common site of injury in a muscle strain.

What are the treatment options for adductor strain?

Once the diagnosis has been established, treatment and prognosis are influenced by factors such as

• Location of tear as those at the junction of the muscle with the bone can be dealt by aggressive rehabilitative treatment
• Degree of strain/ tear
• Duration of symptoms- acute or chronic
• Presence of any biomechanical abnormalities such as muscular imbalances, leg length discrepancy

Acute injuries are initially treated with rest, ice, compression anti-inflammatory drugs and physical therapy with further management dependant of factors discussed earlier. Early treatment is recommended, and injections are used as required.

Education about load management and avoiding provoking factors is important. Activities like running can be replaced with swimming, walking, cycling as having baseline activities is preferred to absolute rest. Specific and individualised exercise programs have a role. A slowly progressive loading program can be used to improve strength and control of adductors, pelvis and lower limbs. The aim of the treatment initially is preventing further injury and inflammation and proving an optimal environment for healing to take place. As recovery occurs, this changes to restoration of range of motion and prevention of atrophy and then subsequently to regaining strength and flexibility.

Injections

This option is considered for individuals’ not responding to conservative measures. Injections are used in combination with physical therapy can help in confirming the diagnosis, providing early, lasting relief and possibly facilitation early return to usual activities. The options include

• Steroid injections
• PRP with or without needle tenotomy
• Obturator Nerve block

Regardless of whichever option is used, ultrasound guidance is valuable in improving accuracy and reducing complications. Sometimes injections of the muscle in the lower abdomen (rectus abdominis muscle) are performed at the same time.

Steroid injections: There are quick to work, commonly performed injections. Steroids have anti-inflammatory effects and it may be all that is required to reduce the pain and help you actively engage with physical therapy. Some studies have shown better effects if the duration of symptoms is less that 6 weeks and hence the importance of early treatment.  Post injection graded increase in activities can be commenced once the pain remains controlled for two weeks.

Platelet Rich Plasma (PRP): PRP injections are commonly used for treatment of tendinopathy and the evidence supporting their use is slowly accumulating. The procedure involves spinning one’s blood in a special machine which separates the platelets (containing the growth factors) from the other blood components. This concentrated platelet layer is then injected into the problem area to induce tissue healing. These injections take time to work with benefits becoming apparent 6 to 12 weeks after treatment. PRP injections are frequently used in combination with needle tenotomy which essentially implies repeated puncturing of the tendon to promote blood flow to the area and induce long-term healing.

Obturator Nerve Block: This injection can have added effect on top of the injections discussed previously. Obturator nerve supplies most of the adductor muscles and hence blocking this nerve can help in reducing the pain signals being transmitted. Injury or compression of the nerve leads to symptoms similar to adductor sprain and is addressed as obturator neuralgia.  Obturator neuralgia can also be secondary to adductor strain and is a known cause of exercise induced groin, inner thigh pain. In this situation obturator nerve block can be especially useful.

Surgery: This option may be considered for acute complete tears with limb weakness or chronic tears with non-satisfactory response to other treatment modalities for a minimum of 6 -12 months. Surgery involves tendon release or dividing the tendon (tenotomy) and this may help to reduce the pain

Restarting activities: Return to play and activity is guided by symptom recovery as well as progress with treatment. Too soon a return is risk factor for repeat injury, which can cause chronic symptoms. Generally, after an acute strain return to sports is recommended on regaining 70% of strength and a painless range of motion. This can be usually achieved between 4 to 8 weeks, although can take up to 6 months chronic injuries. Maintaining adductor strength at a minimum of 80% of abductor strength has been shown to reduce adductor injuries.

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