Case Presentation on: Boxer’ Elbow & Stress Fracture( Fibula)

By: Remon Chettri, Roll No: 15 MSPT: I year.

Index:

1. definition. 2. causes. 3. clinical symptoms 4. diagnosis 5. management 6. case study 7. recent advancements

Boxer’s Elbow:

Valgus Extension Overload Syndrome of the Elbow

An overuse disorder caused by repetitive and uncontrolled valgus forces demonstrated during the throwing motion, especially in late acceleration and deceleration

Also may be seen in boxers

Osteophyte and loose body formation occurs secondary to a repetitive abutment of the olecranon against the fossa

Pathology: Anterior traction on

the coronoid process and posterior compression between the olecranon, trochlea and fossa may generate synovitis, hypertrophic changes and destructive joint changes and even loose bodies.; David C Reid

Clinical Symptoms:

Posterior elbow pain with lack of full extension

Catching or locking during elbow extension

Occasional Snap may be present.

Point of pain

Diagnosis:

History will reveal the condition.

Plain films: AP/lateral may show a loose body or osteophyte formation at the olecranon

Management: Conservative Surgical: Removal of the loose body

Rehabilitation Program:

Physical Therapy ( acute phase ) overuse injuries are treated using

protection, rest, ice, compression, elevation, medications, and modalities (PRICEMM).

Rehabilitation program: Recovery phase:

once the pain is resolved or is improved enough so that strengthening can begin.

Flexibility and strengthening are the main goals of therapy.

Care should be taken not to proceed though this phase too quickly as the overuse syndrome can return.

The athlete may begin with simple ball squeeze and crumbling newspaper with the affected hand, causing gentle strengthening of the forearm muscles.

Maintenance Phase: fulfilled with a home therapy program.

the athlete can perform a preventative program with an athletic trainer or strength and conditioning coach at regular intervals.

Coaches are very important during this phase.

Occasional use of NSAIDs or cryotherapy may be needed.

CASE STUDY:

Name: Sanampal Singh. Age: 18yrs Sex: Male. Occupation: Student ( boxer) Address: Amritsar. Hand dominance: Right.

Chief Complaints: pain on forceful straightening of the left elbow.

HOPI:

Patient was apparently well until a week back he had a bout of boxing match wherein he hit a forceful extension for a punch (JAB) and experienced a sharp pain but then continued for another 2 mins and then he stopped due to pain, the following week he was on rest for a week but pain persisted hence had to report to the Health Centre, OPD on 14th Aug ‘07.

Past History: no relevant injuries. Pain: dull diffused type provocative factor: End range extension palliative factor: rest pain on VAS: 0 4 10

On Observation: no swelling, deformity or skin change

On Palpation: no temperature difference, tenderness felt at the olecranon

process.

On Examination: no tightness. End Extension is limited. MMT : Grade V.

Investigations:

No X-Rays taken.

Goals:

To decrease pain To improve range of motion To prevent further insult to the joint To enhance proper bio mechanics of

the joint Enhance pain free ADL’s Return to Sport activity.

Management: Relief of pain Protection, Rest, Ice, Compression, Elevation, Medications, Modalities (PRICEMM) Moist Packs, Ultrasound,etc.

Control Abuse Modify Intensity, duration, and technique

of forearm activityUse of proper size and type of equipmentCounter-force bracing

Splints and Bracing:

Recent Advancements: use of sensory level high voltage alternating

current in conjunction with pre exercise heat or post exercise ice has demonstrated the most beneficial effects at the Virginia Sportsmedicine clinic;2002.

The program created by Nirschl and Sobel was designed for elbow (tendinosis), the most frequently encountered overuse injuries of the elbow in the clinical setting.

Pain Charting.

Stress Fractures

Definition: Stress fractures are a type of overuse injury.

These tiny cracks in your bones develop when your muscles become overtired (fatigued) and can no longer absorb the shock of repeated impacts.

When this happens, the muscles transfer the stress to the bones, creating a small crack or fracture.

Stress fractures also can occur with normal usage if osteoporosis or some other disease weakens your bones and leaves them vulnerable.

These fractures are often called "insufficiency fractures" because there isn't enough bone to withstand the normal stress of daily use

Most stress fractures occur in the weightbearing bones of the foot and lower leg.

Who is at a risk?

Athletes who participate in high-impact sports such as track and field, basketball, gymnastics, ballet or tennis

Adolescents whose bones have not yet fully hardened

Women, particularly female athletes, who have abnormal or absent menstrual cycles that can result in decreasing bone mass

Military recruits who suddenly must shift from a sedentary civilian life to a more active training regime

Causes:

A stress fracture develops from continued physical stress on the bone rather than from a single blow to the bone. It can be caused by:

Increasing the amount or intensity of an activity too quickly (most common)

Switching to a different playing or running surface

Wearing improper or old shoes

Signs and symptoms Pain that develops gradually, increases with

weight-bearing activity, and diminishes with rest

Tenderness to touch at the site of the fracture

Swelling and warmth at the site of the injury

Localized pain on the bone

Diagnosis:

History will give a clue about the injury.

X-ray: although not confirmatory.

Bone Scans:

MRI:

Treatment: Drugs Nonsteroidal anti-inflammatory drugs (NSAIDs)

can relieve pain.

Rest Rest is the most important thing you can do for a

stress fracture. This includes avoiding the activity that caused the fracture and any other activities that cause pain.

Crutches or a Cane You may need crutches or a walking cane to keep

pressure off the leg, but most people do not.

Prevention: Maintain a healthy diet. Eat calcium-rich

foods to help build bone strength.

Use the proper equipment for your sport. Don't wear old or worn running shoes.

Alternate activities. For example, you can alternate jogging with swimming or cycling.

Slowly increase any new sports activity. Gradually increase time, speed and distance.

Case Study:

Name: Sarabjit Kaur.

Age: 18 yrs Sex: Female.

Occupation: Student; athlete (hand ball)

Add: Amritsar.

Chief Complaint : pain on the right leg during walking and running.

HOPI: Patient was apparently well until 2

weeks back she experienced slight pain but she neglected it for a whole week but did not go for her practiced sessions for the following week , but on 13th Aug he went for a bout of games and then pain increased greatly hence she reported to the Health Centre, OPD on 14th Aug.

Past History : No Complaint of relevance

Pain:

Nature of Pain: dull , aching. Provocative Factors: weight bearing

activities. Palliative Factors: rest. Pain on VAS:

0 6 10

On Observation: No Deformities. Mild localized swelling. No Skin changes.

On Palpation: Temperature: mild warmth. Tenderness: Grade II. On Examination: No Tightness as such. Ranges of Motion within functional limits. Muscle Power : MMT (Kendal’s) Grade 5.

Investigations: X-Ray: slight periosteal

inflammation

Goals: to relieve pain. to prevent further damage.

activity modification.

to strengthen the supporting musculature.

correct Biomechanical cause.

to maintan Ranges of motion

Management:

Rehabilitation Program: activity modification muscle strengthening and generalized

conditioning. anti supination orthotics. achilles rehabilitation ladder Fitness training during the rehabilitation

period should include cross-training so that excessive loading of the affected bone is avoided

Recent Advancements: Treatment consists of activity restriction to minimize

symptoms before engaging in a program of increasingly demanding strengthening and conditioning exercise, leading to an eventual return to play in 8-12 weeks.

3 studies have demonstrated that use of a pneumatic leg

brace allowed athletes to recover more quickly than athletes treated with activity restriction alone (Anderson, 2000; Swenson, 1997; Whitelaw, 1991). It may be that compression of the leg's soft tissues helps to unload the tibia during weight-bearing activities, thereby minimizing further microdamage and facilitating bony repair.

Failure of nonoperative care warrants consideration of surgical intervention. Options include reamed intramedullary nailing and internal fixation with bone grafting. Postoperative recovery time averages 6 months.

Thank You…..