By Dr. Shane Hervey, Center for Sports Medicine, Luskin Orthopaedic Institute for Children

With the holiday season in full effect, there is a transition in sports for our young athletes. Our contact or flag football athletes may be exchanging cleats for the latest basketball shoes, and our volleyball players may be going from the courts to the soccer pitch. With this transition comes a different set of injuries and conditions that your child may experience. As an expert in primary-care sports medicine, I’m here to highlight three common injuries in winter sports, how they happen, how to prevent them and how to treat them.

Ankle sprains
How do they happen? Ankle sprains are one of the most common sports injuries. They occur more frequently in athletes who change directions quickly or jump and land on another athlete. When someone “rolls” their ankle, the ligaments (tissue that connect bones to provide support) are stretched or torn due to the sudden inward or outward movement of the ankle. In addition to the type of sport being played, another risk factor for these injuries is a prior ankle sprain, especially in the 6-12 months following an ankle sprain.

How to prevent ankle sprains from occurring? If your child has recently suffered from an ankle sprain, it is important to regain the strength and stability of that ankle through home exercises and/or physical therapy. Regardless of a recent injury to the ankle, it may be beneficial to support the ankle using a brace or athletic tape.

How to treat them and when can the athlete return to play? A sports medicine physician will examine the ankle and will determine the next steps, including any need for imaging (usually an X-ray to ensure the bones are not broken), rehabilitation, medications, immobilization (in an ankle brace or a walking boot) and crutches. Most simple ankle sprains can be treated with a period of rest, ice, compression and elevation. Additionally, a provider may prescribe a nonsteroidal anti-inflammatory drug (NSAID) to assist with pain and inflammation.

After an ankle sprain, shift the focus to functional exercises as pain improves. The injury disrupts the neuromuscular connection (nerve-muscle communication) by damaging the ankle’s sensors (proprioception), which leads to poor balance and a higher risk of re-injury [1][6-7]. 

Physical therapy is essential for retraining this connection through balance and strength exercises, which restore stability and significantly reduce the chance of future sprains [4-6]. A home exercise program may also be prescribed by your physical therapist and/or physician. Return to sport is safe when the athlete can perform running, jumping and cutting motions without pain.

Patellar tendinopathy (“Jumper’s Knee”)
What is patellar tendinopathy? A tendon connects a muscle to a bone. The patellar tendon connects the kneecap (patella) to the top of the shin bone (tibia). Patellar tendinopathy, also known as jumper’s knee, occurs with repeated stress to the patellar tendon from activities like repetitive jumping, running, cutting or changing direction. This repeated stress causes tiny tears to the tendon, leading to degeneration and, in turn, pain to the front of the knee.

How to prevent patellar tendinopathy from occurring? As mentioned by Luskin OIC Sports Medicine Associate Director, Dr. Joshua Goldman, gradually increasing training volume can decrease the risk of developing overuse injuries such as patellar tendinopathy. Ensuring correct running, jumping and landing mechanics by strengthening the muscles in the buttocks, thighs, lower legs and core (abdominal muscles) can help prevent patellar tendinopathy.

How to treat this condition? The first step in treatment is often a period of rest to reduce stress on the tendon. To help with symptoms of pain and/or swelling, it may also be beneficial to use a patellar strap, knee brace and ice. Occasionally, NSAIDs can be used to help with pain. An essential part of treatment is strengthening the muscles in the leg through physical therapy. For tendon healing, research supports progressive tendon loading (like isometric holds) and eccentric exercise therapy. Eccentric exercises specifically strengthen the muscle while lengthening the tendon, such as slowly controlling the return phase of a knee extension machine [2]. It is important to note that it may take months of rehabilitation to allow for tendon healing.

ACL injury
How do ACL injuries occur? The anterior cruciate ligament (ACL) is one of four major ligaments of the knee. Ligaments connect one bone to another. The ACL connects the femur or thigh bone to the tibia or shin bone. The other three are the posterior cruciate ligament (PCL), the lateral collateral ligament (LCL) and the medial collateral ligament (MCL). The ACL is the most important ligament of the knee when an athlete suddenly stops, cuts or pivots. ACL injuries can range from a sprain (stretching of the ligament without tearing) to a partial or full-thickness tear of the ACL. Most ACL injuries are non-contact injuries, where an athlete doesn’t make contact with another object or person, though they may also be caused when one athlete collides with another. Muscle imbalance, female biology (may be related to hormone fluctuations as it relates to menstrual cycle; [3]), prior ACL injury and intensity of physical activity are risk factors for ACL injury (as these injuries tend to happen during games rather than practices).

How to prevent ACL injuries from occurring? Exercise programs guided by an athletic trainer, physical therapist or other trained professional that focus on plyometrics, strength, agility, balance and feedback on movement technique may reduce the risk of ACL injury. An example of this is our Luskin OIC injury prevention program. Prevention exercises should start in the preseason and continue throughout the season. Proper warmups, balance training and having a professional evaluate for individuals at risk (such as those with prior ACL injury) may also help prevent these injuries from occurring.

How to treat ACL injuries? Sports medicine professionals can assess the stability of the ACL with a physical examination. It can be difficult to accurately assess the ACL immediately after an injury due to pain and swelling. X-rays can help evaluate for an injury to bone, while magnetic resonance imaging (MRI) can confirm an ACL injury and other potential soft-tissue injuries. Initial treatment consists of bracing, rest, ice, compression, elevation, pain management and potentially crutches. If testing is concerning for a complete tear of the ACL, our surgical colleagues, who are experts in reconstructing the ACL after injury, are often consulted. However, it is important to mention that not all ACL injuries require surgery. The decision is multi-factorial, with considerations such as the type of activity you desire returning to and whether or not other structures in the knee were injured with the original injury. If surgery is the option for you, surgery likely won’t happen right away. Pre-surgery exercise rehabilitation or “pre-hab” is paramount to restore range of motion, allow time for reduced swelling and build muscular strength, all of which will contribute to an optimal recovery. Return to sport is generally dependent on multiple factors, and it can be expected that 9-12 months of recovery and rehabilitation are needed for complete ACL tears treated with surgery.

References

1. Alghadir AH, Iqbal ZA, Iqbal A, Ahmed H, Ramteke SU. Effect of Chronic Ankle Sprain on Pain, Range of Motion, Proprioception, and Balance among Athletes. Int J Environ Res Public Health. 2020;17(15):5318. Published 2020 Jul 23. doi:10.3390/ijerph17155318.
2. Breda SJ, Oei EHG, Zwerver J, et al. Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial. Br J Sports Med. 2021;55(9):501-509. doi:10.1136/bjsports-2020-103403.
3. Herzberg SD, Motu’apuaka ML, Lambert W, Fu R, Brady J, Guise JM. The Effect of Menstrual Cycle and Contraceptives on ACL Injuries and Laxity: A Systematic Review and Meta-analysis. Orthop J Sports Med. 2017 Jul 21;5(7):2325967117718781. doi:10.1177/2325967117718781. PMID: 28795075; PMCID: PMC5524267.
4. Holmes A, Delahunt E. Treatment of common deficits associated with chronic ankle instability. Sports Med. 2009;39(3):207-224. doi:10.2165/00007256-200939030-00003.
5. Kaminski TW, Hertel J, Amendola N, et al. National Athletic Trainers’ Association position statement: conservative management and prevention of ankle sprains in athletes. J Athl Train. 2013;48(4):528-545. doi:10.4085/1062-6050-48.4.02.
6. Martin RL, Davenport TE, Fraser JJ, et al. Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021. J Orthop Sports Phys Ther. 2021;51(4):CPG1-CPG80. doi:10.2519/jospt.2021.0302.
7. Mattacola CG, Dwyer MK. Rehabilitation of the Ankle After Acute Sprain or Chronic Instability. J Athl Train. 2002;37(4):413-429.