The Concussion Injury

The Anatomy (from The Hughston Clinic)

The brain is composed of soft tissues encased within the hard bone of the skull. A concussion occurs when your head is hit or jolted and your brain's soft tissue moves in reaction to the sudden force. At impact with the skull, the brain can become bruised, tissues can be torn, and minor swelling can occur. An injury to the brain can cause neurons (nerve cells) and nerve tracts (neurological pathways) to change or not function properly. The changes in brain function can change the way you think, act, or feel.

Three membranes, collectively called the meninges, provide protection by separating the brain's soft tissue from the rigid wall of the skull. Three layers cover the brain; the dura, a tough, leathery outer covering; the arachnoid, a thin inner layer with threadlike strands that attach it to the pia mater; and the pia mater, which is a thin, delicate layer tightly attached to the surface of the brain. In addition to the protection of the layers, cerebrospinal fluid surrounds the brain and cushions it as well. Even with these protections, the meninges and deeper tissues within the brain can become bruised when there is a blow or jolt to the head or when the head is severely jarred or shaken.

Signs and Symptoms

The signs and symptoms of a concussion can be subtle and may not appear immediately. Symptoms can last for days, weeks or longer.

The two most common concussion symptoms are confusion and amnesia. The amnesia, which may or may not be preceded by a loss of consciousness, almost always involves the loss of memory of the impact that caused the concussion.

Other immediate signs and symptoms of a concussion may include:

• Headache
  
• Dizziness
  
• Ringing in the ears
  
• Nausea or vomiting
  
• Slurred speech

Some symptoms of concussions don't appear until hours or days later. They include:

• Mood and cognitive disturbances
  
• Sensitivity to light and noise
  
• Sleep disturbances

Head trauma is very common in young children. But concussions can be difficult to recognize in infants and toddlers because they can't readily communicate how they feel. Nonverbal clues of a concussion may include:

• Listlessness, tiring easily
  
• Irritability, crankiness
  
• Change in eating or sleeping patterns
  
• Lack of interest in favorite toys
  
• Loss of balance, unsteady walking

Screening and Diagnosis

Diagnosing a concussion is usually straightforward. If a blow to your head has knocked you out or left you dazed, you've had a concussion. It's more difficult, however, to determine whether the blow has caused potentially serious bleeding or swelling in your skull. Signs and symptoms of these injuries may not appear until hours or days after the injury.

Your doctor may start your evaluation with questions about the accident, then proceed to a neurological exam. This exam includes checking your memory and concentration, vision, hearing, balance, coordination and reflexes.

The standard test to assess post-concussion damage is a computerized tomography (CT) scan. A CT scanner takes multiple cross-sectional X-rays and combines all the resulting images to produce detailed, two-dimensional images of your skull and brain. During the procedure, you lie still on a table that slides through a large, doughnut-shaped X-ray machine. The scan is painless and generally takes less than 10 minutes.

Not every concussion requires a CT scan, but the test is usually done as a precaution if there's a chance your injury is more severe than your immediate condition suggests.

You may need to be hospitalized overnight for observation after a concussion. If your doctor says it's OK for you to be observed at home, someone should check on you periodically for at least 24 hours. You may need to be awakened every two hours to make sure you can be roused to normal consciousness. Post-concussion syndrome, a poorly understood complication, as it causes concussion symptoms to last for weeks or months.

USC wide receiver Vidal Hazelton underwent surgery for two muscle tears in his stomach that bothered him most of last season.

Hazelton played last season with what was thought to be a groin injury, but turned out to be multiple stomach tears. He is expected to be fully recovered for spring practice, which begins next month.

The surgery was performed in Philadelphia by Dr. William Meyers of Drexel University.

USC rarely sends an athlete to the Northeast for an operation, but Hazelton's family insisted the surgery be performed by an expert in abdominal surgery.

What is a sports hernia?

A sports hernia occurs when there is a weakening of the muscles or tendons of the lower abdominal wall. This part of the abdomen is the same region where an inguinal hernia occurs, called the inguinal canal. When an inguinal hernia occurs there is sufficient weakening of the abdominal wall to allow a pouch, the hernia, to be felt. In the case of a sports hernia, the problem is due to a weakening in the same abdominal wall muscles, but there is no palpable hernia.

What is the inguinal canal?

The inguinal canal is a region in the lower abdomen, just above the groin. The canal is formed by the insertions of abdominal muscles and tendons, as well as several ligaments. Within the inguinal canal travels the spermatic cord (in males) or the round ligament (in females). This area of the abdomen is prone to weakening of the abdominal wall, allowing an outpouching, or hernia, to form.

The Abdominal Muscles

The abdominal wall is made up of several muscles. These include:

• Rectus Abdominis: the muscle over the front of the belly-this muscle give people a "six-pack" appearance when the rectus is well developed.
• Internal and External Oblique: the obliqes wrap around the sides of the body.

Abdominal muscle strains are graded according to the severity of the injury:

• Grade I (Mild): Mild discomfort, often no disability. Usually does not limit activity.
• Grade II (Moderate): Moderate discomfort, can limit ability to perform activities such as crunches or twisting movements.
• Grade III (Severe): Severe injury that can cause pain with normal activities. Often patients complain of muscle spasm and bruising.

Abdominal muscle strains are graded according to the severity of the injury:

• Grade I (Mild): Mild discomfort, often no disability. Usually does not limit activity.
• Grade II (Moderate): Moderate discomfort, can limit ability to perform activities such as crunches or twisting movements.
• Grade III (Severe): Severe injury that can cause pain with normal activities. Often patients complain of muscle spasm and bruising.

The problem with the abdominal wall in people with a sports hernia is not a muscle strength issue. Rather, the abdominal wall in a particular region is too thin, allowing the hernia to form. The sports hernia does not occur in the area of the large, thick part of the muscle.

Symptoms

A sports hernia typically begins with a slow onset of aching pain in the lower abdominal region. Symptoms may include:

• Pain in the lower abdomen
  
• Pain in the groin
  
• Pain in the testicle (in males)

Typically the symptoms are exacerbated with activities such as running, cutting, and bending forward. Patients may also have increased symptoms when coughing or sneezing. Sports hernias are most common in athletes that have to maintain a bent forward position, such as hockey players. However, sports hernias are also found in many other types of athletes such as football and soccer players. Treatment

There are no treatments that have been shown to be effective for sports hernia other than surgery. That said, the initial treatment of a sports hernia is always conservative in hopes that the symptoms will resolve. Resting from activity, anti-inflammatory medications, ice treatments, and physical therapy can all be tried in an effort to alleviate the patient's symptoms.

If these measures do not relieve the symptoms of a sports hernia, surgery may be recommended to repair the weakened area of the abdominal wall. In number of studies have shown between 65% and 90% of athletes are able to return to their activity after surgery for a sports hernia. Rehabilitation from surgery for a sports hernia usually takes about eight weeks.

Laproscopic Hernia repair

A number of factors have led to the recent development of a new method of repair called laparoscopic hernia repair. This technique is really an extension of a traditional mesh repair method that was used in patients who had already experienced several hernia recurrences at the same site.

Previously, this mesh repair approach had required a separate incision somewhat removed from the target area. However, with the progressive development of the instruments and techniques for laparoscopic surgery, the same procedure can now be done with several relatively small incisions.

This allows the surgeon to enter the space behind the hernia defect and place the mesh with minimal injury to the surface of the abdomen. The advantages of this method include coverage of all the potential sites of groin hernia, which reduces the risks of recurrence while also decreasing the amount of post-surgical pain.

The Hamstring Muscle Group

Classifications of the Injury

Sprains and strains are caused by excessive stretching (tearing) of muscle fibers soft tissues. Hamstring strains are classified as Grade I (mild), Grade II (moderate), or Grade III (severe) degree strains depending on the severity.

Grade 1: Consists of minor tears within the muscle.

    * May have tightness in the posterior thigh.

    * Probably able to walk normally however will be aware of some discomfort.

    * Minimal swelling.

    * Lying on front and trying to bend the knee against resistance probably won't produce much pain.

Grade 2: Is a partial tear in the muscle.

    * Gait will be affected-limp may be present .

    * May be associated with occasional sudden twinges of pain during activity.

    * May notice swelling.

    * Pressure increases pain.

    * Flexing the knee against resistance causes pain.

    * Might be unable to fully straighten the knee.

Grade 3: Is a severe or complete rupture of the muscle.

    * Walking severely affected- may need walking aids such as crutches

    * Severe pain- particularly during activity such as knee flexion.

    * Noticeable swelling visible immediately.

Treatment

Treatment may depend upon the severity of the injury, with third degree strains requiring a doctor's evaluation. In general the following tips are used for most muscle strains.

• After an injury it's important to rest the injured muscle, sometimes for up to two or three weeks.
• RICE - Rest, apply Ice and Compression. Elevate the leg if possible.
• An anti-inflammatory can be helpful to reduce pain and inflammation.
• A stretching program can be started as soon as the pain and swelling subsides.
• A strengthening program should be used to rebuild the strength of the injured muscle in order to prevent re-injury. Make sure you increase this gradually.
• A thigh wrap can be applied to provide support as the muscle heals.

Surgical Treatment

Avulsion Repair

Surgery is rarely needed for hamstring injuries. However, it may be needed for an avulsion to reattach the torn hamstring tendon to the pelvis. If surgery is delayed after an avulsion, the tendon may begin to retract further down the leg, and scar tissue may form around the torn end of the tendon. Both of these factors make it more difficult to do the surgery.

To begin the operation, an incision is made in the skin over the spot where the hamstring tendon normally attaches to the pelvis. The surgeon locates the torn end of the hamstring tendon. Forceps are inserted into the incision to grasp the free end of the torn hamstring tendon. The surgeon pulls on the forceps to get the end of the hamstring back to its normal attachment. The surgeon cuts away scar tissue from the free end of the hamstring tendon.

 The original attachment on the pelvis, the ischial tuberosity, is prepared. An instrument called a burr is used to shave off the surface of the tuberosity. Large sutures or staples are used to reattach the end of the hamstring tendon to the pelvis.

When the surgeon is satisfied with the repair, the skin incisions are closed.

Muscle Repair

Surgery may be needed to repair a complete tear of a hamstring muscle. An incision is made over the back of the thigh where the hamstring muscle is torn. The muscle repair involves reattaching the two torn ends and sewing them together.

What is a Hip Pointer?

A hip pointer is an injury to the pelvis caused by a direct blow, often seen in contact sports such as football. The term hip pointer is somewhat confusing. It can refer to a deep bruise of the muscle and bone, a small chip fracture or even a complete break. Typically, however, this term refers to a severe bruise and not a fracture.

What happens when an athlete gets a hip pointer?

A hip pointer is an injury is to the iliac crest, the bony prominence that can be felt along the waist line. Spearing the hip/pelvis with a helmet while tackling may be the most common cause.When someone sustains a hip pointer injury, the bone and overlying muscle can be bruised.

In more serious cases of hip pointer, the hit can be so severe that a fracture of the bone results. While the treatment may not change, a fracture will likely cause a delay in healing and more painful symptoms.

Diagnosis:

The patient may walk with a limp and have difficulty moving the hip away from the body against resistance. X-rays are taken to rule out fractures. Occasionally, further studies may be indicated if the patient's symptoms do not improve with treatment.

Treatment:

Treatment of a hip pointer is best accomplished with rest. Ice applications and anti-inflammatory medication will also help, but only time will heal the injury. Again, X-rays may be taken if a fracture is suspected.

Surgery is very rarely indicated. It is usually reserved for patients with significant displacement of fractures of bone where the muscles attach around the pelvis.

The shoulder joint is made of three bones which come together at one place. The arm bone or humerus, the shoulder blade or scapula, and the collarbone or clavicle all meet up at the top of the shoulder. A shoulder separation occurs when there is an injury to the joint between the scapula and clavicle--this is called an acromioclavicular or an A-C separation, as discussed here. A shoulder dislocation occurs when there is an injury to the joint between the humerus and scapula.

The joint between the humerus and scapula, also called the glenohumeral joint, is a ball-and-socket joint- the ball is on the top of the humerus, and this fits into a socket of the shoulder blade called the glenoid. This joint is incredible because it allows us to move our shoulder though an amazing arc of motion- no joint in the body allows more motion than the glenohumeral joint. Unfortunately, by allowing this wide range of motion, the shoulder is not as stable as other joints. Because of this, shoulder dislocations are not uncommon injuries.

Diagnosis The diagnosis of a dislocated shoulder is made by the combination of the history of injury, signs and symptoms on physical exam, and by x-rays that show that the humeral head is out of the socket. The diagnosis of subluxation is made the same way, but the humeral head will still be in the socket because it has not completely dislocated. Occasionally, an MRI is used to look at these injured soft tissues.

After the shoulder has been put back in the socket, the severe pain will stop almost immediately. The structures such as the labrum, bone, nerves, or ligaments were injured must be evaluated. The treatment that follows depends on what structures were injured, how many dislocations you have had, how unstable the shoulder is and how much pain you have. Immobilizization of the shoulder in a sling or sling and side pillow is done for a few weeks while the injury heals.

TREATMENT

Conservative nonoperative treatment including physical therapy to strengthen the muscles around the shoulder (rotator cuff) is best after the first dislocation. If you have had multiple dislocations or subluxations, surgery is suggested to repair or tighten the capsule and ligaments that hold the shoulder in place. If the labrum has been injured, it will need to be trimmed or sutured. The surgery is usually done arthoscopically, which is less invasive and offers quicker return to full activity. The surgery is performed with an arthroscope and small instruments introduced into the shoulder joint through hollow cannulas. Miniature anchors or screws with suture attached are inserted precisely into the socket edge of the shoulder, and the torn ligaments and labrum are reattached to the socket. Complete healing from this procedure takes approximately 4-6 months.

The older a patient is at the time of dislocation the lower the chances are for developing recurrent dislocations. Patients over 35-40 can tear the rotator cuff with a dislocation. Patients under the age of 25 with traumatic dislocations have a substantially higher rate of recurrence (greater than 80-90%).

From C. Thomas Vangsness, Jr., MD
Chief, Sports Medicine Service, LAC/USC Medical Center
Team Physician, USC Department of Athletics

What is a knee bone bruise?

Bone bruises are also known as periosteal. The most painful bruises, they can sometimes take months to heal. What happens in a bone bruise is a compressive force pushes the bone in on itself. When this happens the outer layer of the bone, the Periostium which is fibrous, breaks down. This leads to leaking of fluid.

The term knee bone bruise is a misnomer, as the knee isn't a bone. The effected area is actually the tip of the femur where it connects to the knee.

What the symptoms of a knee bone bruise?

You're going to have soreness and pain to the touch as you do with a normal bruise, but a bone bruise will typically not swell. It'll be difficult to walk, and there may be discoloration in the area of the knee bone bruise.

Low ankle sprains are among the most common injuries which occur in sports. In this type of ankle sprain, an athlete steps incorrectly on his or her foot or skate, and the ankle and foot turn in. This results in the structures in the outside portion of the ankle being stretched. The amount of stretch can vary from a mild, moderate, or a severe amount. In severe stretches, the ligaments which hold the ankle together are completely torn.

In a low ankle sprain, the ligaments which hold the fibula to the dome of the ankle (the talus) are stretched or torn. These types of ankle sprains usually are more stable and can be treated with a program of taping and rehabilitation once the initial pain and swelling from the injury subside. Most athletes return back to activities by one to three weeks after injury.

In high ankle sprains, the membrane which connects the two leg bones (the syndomosis) is either stretched or torn. High ankle sprains can be especially problematic for athletes because there is a very poor blood supply to this area of the ankle and it takes a long time to heal. Any type of twisting or turning maneuver results in stretching of this area, which makes it especially difficult to play basketball, soccer, or to skate. Over time, athletes who have a high ankle sprain can often walk and even jog on level ground normally, but cannot push off on their skate edges and are limited in terms of their ability to return to activities. High ankle injuries can take six weeks or longer to heal.

MRI of a torn Triceps

About the Triceps

From Wikipedia

The triceps accounts for approximately 60 percent of the upper arm's muscle mass, but people who exercise the arms with weights often neglect this group of muscles in favor of the biceps brachii.

The triceps can be worked through either isolation elbow extension movements, contract statically to keep the arm straightened against resistance, or compound pressing movements.

Isolation movements include cable push-downs, "skull-crushers", and arm extensions behind the back.

Static contraction movements are pullovers, straight-arm pulldowns, and bent-over lateral raises, which are also used to build the rear deltoids and latissimus dorsi.

Examples of pressing movements are press ups, bench presses (level, incline or decline), military presses and dips. Using a closer grip stabilizes the arm allowing more weight to be used, so the triceps can be worked harder without being limited by the strength of the pectorals or shoulders.

Elbow extension is important to many athletic activities. As biceps are often worked more for aesthetic purposes, this is usually a mistake for fitness training. While it is important to maintain a balance between the biceps and triceps for postural & effective movement purposes, what the balance should be and how to measure it is a conflicted area. Pushing and pulling movements on the same plane are often used to measure this ratio.

The American Journal of Sports Medicine 32:431-434 (2004)
© 2004 American Orthopaedic Society for Sports Medicine

Triceps Tendon Ruptures in Professional Football Players

Scott D. Mair, MD^*,, William M. Isbell, MD, Thomas J. Gill, MD, Theodore F. Schlegel, MD and Richard J. Hawkins, MD^||

From the University of Kentucky Sports Medicine, Lexington, Kentucky, Massachusetts General Hospital, Boston, Massachusetts, Steadman Hawkins Clinic, Denver, Colorado, and ^|| Steadman Hawkins Clinic, Vail, Colorado

^* Address correspondence to Scott D. Mair, MD, University of Kentucky Sports Medicine, 740 South Limestone, K-401 Kentucky Clinic, Lexington, KY 40536-0284.

Background: Distal rupture of the triceps tendon is a rare injury, and treatment guidelines are not well established.

Hypothesis: Football players with triceps tendon ruptures will be able to return to their sport with minimal functional deficits.

Study Design: Uncontrolled retrospective review.

Methods: Twenty-one partial and complete ruptures of the triceps tendon were identified in 19 National Football League players over a period of 6 years. Team physicians retrospectively reviewed training room, clinical, and operative notes for each of these players.

Results: Most of the injured players were linemen. The most common mechanism of injury was an eccentric load to a contracting triceps. Seven players had prodromal symptoms prior to injury, and 5 had received a cortisone injection. Eleven elbows with complete tears underwent surgical repair. Of 10 players with partial tears, 6 healed without surgery. One player suffered a subsequent complete tear requiring surgery, and 3 with residual pain and weakness underwent surgical repair following the season. Two surgical complications occurred, both requiring a second operation. All of the players but 1 returned to play at least one season of professional football after their injury.

Conclusions: Partial triceps tendon ruptures can heal without functional deficit. Surgical repair for complete ruptures generally produces good functional results and allows return to play.