Referee Lesions J

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JOÃOESPREGUEIRA-MENDES, CARLOSARCE

Introduction

Referees are a fundamental group in the professional sports world. However, no articles about referee injuries have been published over the past few years.

This article is an attempt to review the most frequent lesions in this group. In a telephone survey of Portuguese referees, we found that the most frequent lesions among this group were muscle lesions and ankle sprains. Those lesions occur especially in reverse running or sprinting and in most cases, at the beginning or end of the game.

Muscle Injuries

Muscle injuries are among the most frequent sport lesions in football – referees included. They can be caused by a direct blow (extrinsic) or, more frequently, an indirect mechanism (intrinsic). The bi-articular muscles are more prone to indirect injuries, as they can change from asynergy to violent contraction with simultaneous stretch due to hip flexion and knee extension. The muscles most frequently affected are the quadriceps (specially the anterior rectus) and the hamstrings.

The quadriceps is one of the most common site of running injuries.

Different anatomical sites within this structure can be involved. A thorough examination of the extensor mechanism includes an assessment of quadriceps strength, contracture, and the position of the vastus medialis obliquus, as well as position, tracking, stability, and mobility of the patella.

Hamstring injuries are a frequent source of acute injury and chronic pain in referees. Hamstring muscle injuries primarily occur proximally and later- ally, and they usually involve the biceps femoris. Changing direction is the most common cause of biceps rupture in two different ways: the biceps acts as an engine in valgus, flexion, external rotation with 5 antagonists (quadriceps, semi-membranosus, semi-tendinosus, sartorius, and gracilis). On the

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other hand, the 5 antagonists are the engine in varus, flexion, internal rotation, and braking. Injuries often occur at the proximal myotendinous junction. In the biceps femoris, this junction extends over most of its entire length. Injury usually does not occur within the tendon itself unless there is a pre-existing pathology. Careful evaluation and correct diagnosis is crucial.

Bony avulsion at the ischial origin may occur as well but usually is associated with sudden, large-force, hip-flexion injuries. Avulsions are commonly seen in people when the knee is extended and the hip is suddenly flexed.

The great majority of muscle lesions do not need surgical treatment and can be repaired with conservative measures. Nevertheless, surgery is indicat- ed in specific cases. Reasons for surgical treatment are:

- Failure of conservative measures (orthopaedic, physiotherapy or others) - Risk of long-term sport inactivity

- An acute lesion that became chronic.

Anatomo-physiology

The skeletal muscle consists of a contractile tissue with a tendino-aponeurot- ic skeleton. In the long muscles of the upper leg, the short disposition of the fibres creates a great isometric force but a poor length variation and shorten- ing velocity. Myoaponeurotic and myotendinous transitions, where stiffness of the connective tissue opposes muscle tissue, are the weakest part of the muscle, being the region more frequently affected in muscle injuries.

Risk Factors

Several factors increase the risk of muscle injuries, among them, age, previous lesion, fatigue, inadequate warming up, bi-articular muscles, and a large quantity of type II fibres. A sports-related injury is most likely to occur when the referee experiences any change in use of the involved structure. This is a rate-dependent process. If training is within the physiological range, there is cellular homeostasis. Insufficient training is associated with disuse, which can cause a catabolic response that ultimately leads to injury. It is common that referees do not have enough time to train adequately. Transitional risks include: 1) improper training; 2) changes in equipment; 3) environmental changes, such as new surfaces or different altitudes; 4) alteration in frequency, intensity, or duration of training; 5) attempts to master new techniques;

6) a return to sports activity too soon after an injury with poor muscle recovery; 7) an unbalanced diet; 8) technical errors; 9) drug ingestion; 10) poor game-field conditions. Commonly affected muscles beyond quadriceps and hamstring are calf and adductors.

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Diagnosis

Diagnosis of muscular lesions is clinical with image confirmation. Clinical observations are:

- Sudden pain;

- Dilaceration sensation;

- Functional incapacity;

- Inspection: swelling, bruises, and tension;

- Palpation: painful spot, depression, or muscular contraction;

- Pain on passive stretching or resistive contracture.

Imaging

An x-ray is mandatory in diagnosing a muscle injury because it can show a bony avulsion or a calcified myositis. Ultrasound is the test choice for study- ing the traumatised muscle. It detects haematoma, discontinuity of muscular fibres, muscle aponeurosis, or myotendinous rupture. Magnetic resonance imaging (MRI) is also highly sensitive and specific for muscle-lesion diagnosis. In MRI, muscle appears with intermediate density wrapped in low signal intensity (aponeurosis). Fat suppression enhances muscular signal. T2- weighted MRI is best for ruptures and T1-weighted MRI for haematomas.

Indications for MRI are:

- Study of profound muscles

- Disagreement between clinical examination and ultrasound - Professional level of the referee.

Acute Muscle Injuries

Direct trauma (extrinsic mechanism):

• Contusion

Indirect trauma (intrinsic mechanism):

• Contracture

• Distension

• Rupture.

Lesions near the insertion point cause large haematomas with large clots difficult to evacuate by aspiration. The only formal indication for surgical treatment of the hamstring is a complete rupture at or near the origin of the ischial tuberosity or distally at its insertion point (either a soft tissue avulsion with a large defect, a bony avulsion from the isquion with displacement superior to 2 cm or a bony distal avulsion). These must be operated and re-insert-

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ed to avoid pain and residual loss of power and function. Late repair is more difficult because of scar tissue and adhesions. The use of anchors is helpful to obtain proper reinsertion. In rare cases, symptoms of sciatic dysfunction can appear, and nerve dissection is necessary.

The length of immobilisation is, however, dependent on the grade of injury and should be optimised so that the scar bears the pulling forces that

Type I

Irreversible in some muscle fibres with full integrity of the supporting con- nectin tissue

Recovery in a few days

Type II

Irreversible with moderate involvement of connective tissue with no disorganisation

Selective pain with no immediate stopping during sport

Healing in 10–15 days

Return to sport- ing activity after recovering muscle strength;

stretching and resistive contraction with no pain

Type III

Muscular lesion with significant involvement of connective tissue

Marked muscular disorganisation with localised muscular haematoma

Acute, severe pain with immediate functional incapacity

Recovery in 6–12 weeks

Special care when recovering force and elasticity

Type IV

Total or near-total rupture

Functional impairment

Surgery must be considered depending on location

12–18 weeks of recovery Type 0

Reversible

Moderate pain

Muscle contraction with im- paired strength

Recovery in hours

Table 1.Rodineau and Durey classification

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operate on it without re-rupture. Early mobilisation is required to regain original muscle strength and to achieve good final results in resorption of the connective tissue scar and vascularisation of the damaged area. Another important aim of early mobilisation, especially in sports activities, is to avoid atrophy and loss of strength and extensibility.

Surgical indications are very rare and include:

- Muscle hernia if painful and stretched between the aponeurosis;

- Complete and large muscle belly ruptures with large haematoma in high- level athletes;

- Traumatic, complete muscle dilaceration;

- Open injuries.

Surgical technique

Surgical treatment of muscle injuries is not comparable with tendon repair, specially the end-to-end rule. It is not necessary to suture the muscle end to end. It is important to remove clots, haematoma, and necrotic tissue and clean the cavity. Necrotic fibres have the ability to form an anarchic tissue, which can progress to calcification. The purpose of surgery is three-fold: decrease pain related to tension, avoid formation of an anarchic painful scar tissue, and achieve the best local tension to maintain muscle strength.

Chronic Lesions

Chronic muscle lesions are related to an event with a more than 3-month evo- lution period. Patients, either high-level or leisure-sport athletes, present after unsuccessful conservative treatment and often following several unsuccessful attempts to re-initiate physical activity and after a long period of inactivity.

Another typical case is the patient with recovery, early return to sports, and re- injury. Re-injury rates from 5% to 77% are reported in the literature and are related with areas of calcification, inflammation, and scar tissue. Chronic lesions are: painful scar tissue, cysts, and myositis ossificans. Myositis ossificans can occur as a muscle ossification of a deep haematoma after trauma and must be distinguished from osteogenic sarcoma. It is often an asymptomatic radiographic discovery. It can be the result of repeated ruptures (in our series, from 1 to 12) or direct trauma and appears 3–6 weeks after the first accident.

Usually, the diagnosis was not made, and the athlete had a premature return to sports activities. Rehabilitative treatment includes early and deep massage, active mobilisation, early return to sports, and infiltrations. The best treatment is prevention, and the first treatment measures are conservative without massage. Surgical treatment must only be proposed after failure of all the other procedures and always after “cooling” of the bone scan.

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Treatment Objective

Treatment objectives are to:

- Obtain global healing, it being important to achieve good vascularity, tissue innervation, and traction (strain) for the fibres;

- Avoid chronicity;

- Avoid recurrence.

Principles

Principles to be attained are to:

- Limit haematoma volume;

- Obtain early tension of muscular fibres;

- Utilise anti-fibrosis measures (ultrasound, decorin, corticosteroids, and platelet growth factors);

- Maintain treatment protocol for a longer period if lesion severity demands it.

Therapeutic protocol

The treatment protocol consists of:

- Rest, ice, compression, elevation (RICE) and muscle relaxants;

- Athermic physiotherapy, non-vibrating; draining massage at 48 h;

- Between 3rd and 10th day (according to lesion type), passive stretching and physiotherapy (heat and low-frequency current);

- Postural stretching, active isotonic contraction, and resistive contraction;

- Proprioceptive exercises;

- No-load exercise (bike, swimming);

- Return to normal activity with progressive intensity if no pain. Before maximum load, perform maximum stretching with no pain;

Treating muscular lesions and early mobilisation are beneficial because they:

- Increase initial haematoma;

- Increase the number of inflammatory cells;

- Increase absorption;

- Facilitate regeneration, achieving better fibre orientation.

Frequency

In our series, the frequency of muscle lesions represented more than 50% of referee injuries. Hamstring injuries represented 30% of lower-extremity injuries in sports medicine consultation over the last 3 years in persons aged

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15–25 years and more than 50% of all muscle lesions. These injuries most often occur in sports in which the hamstrings can be stretched eccentrically at high speed with sprinting or running contact sports, such as football.

Recreational sports, such as water skiing, in which the knee is fully extended during injury, also are common causes of hamstring injuries. In 256 individuals with hamstring injuries 74% of injuries were in football, 16% in track, 8% in rugby, and less than 2% in tennis, squash, ballet, and gymnastics.

Rehabilitation Program

Treatment varies according to injury severity and surgical difficulties. Up to 1 week, the focus of therapy is to limit pain, inflammation, and swelling. Rest, ice, and elevation are recommended. Icing for 20 min, 4 times per day pro- vides pain relief. Following surgery, some individuals need immobilisation with the in knee extension for 1–5 days to prevent contracture formation and damage to the suture/re-insertion. Crutches enable ambulation while resting the injured leg. After several days, most patients may begin pain-free isometric exercises, pool therapies (after skin healing), and upper-body exercises.

Isometric exercises are performed at various knee angles in increments of 20°. Generally, treatment 1–6 weeks postoperatively focuses on strengthening, improving range of motion (ROM), and flexibility. Passive static stretching may begin at this stage. Electrical stimulation may be used in conjunction with ice for added pain relief. The patient may exercise, preferably with a therapist, to strengthen the muscle within the available pain-free ROM. Then the patient begins isotonic exercises with resistance increasing gradually as tolerated. As healing continues, high-speed, low-resistance isokinetic exercises can begin. Resistance is increased gradually while exercise speed is decreased. Over time, the patient progresses from concentric to eccentric strengthening exercises. Prior to returning to play, sports-specific training maximises recovery and minimises chances for additional injury.

Return to Activity

A common threshold for return to the field is when the strength of the injured muscle has at least 90% of the strength of the unaffected side and when the patient has full ROM. In a hamstring lesion, at least a 50–60% hamstring-to- quadriceps ratio is desired prior to return to play. Strength testing is performed using isokinetic exercise equipment. In addition, it is also important to ensure return of normal flexibility and endurance prior to return to play;

re-injury most often is due to lack of both. Therapy that incorporates sports- specific activities can help minimise the risk of re-injury.

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Complications

Complications following treatment include:

- Re-injury;

- Failure of healing related to early active mobilisation;

- Relapse of painful scar tissue;

- Relapse of calcification;

- Atrophy and decrease of strength.

Surgery

Surgical treatment of muscular lesions is rare and with a very few and precise indications. In acute lesions, indications are as follows:

- Compressive haematoma (with risk of a compartment syndrome) secondary to near-total ruptures;

- Complete proximal or distal disinsertions;

- Total rupture with important retraction;

- Sciatic nerve dysfunction;

For chronic lesions, indications are as follows:

- Painful scar;

- Painful fibrous muscular scar;

- Chronicle seroma or cyst;

- Painful muscular hernia;

- Painful ossification of the periosseous.

Prevention

Prevention is the key to avoiding muscular lesions and could be divided into three main parts as follows:

- Primary prevention

• Medical examinations

• Dietary control

• Training flexibility and stretching

• Avoiding drugs

• Warming up and cooling down

• Progressive training

• Personal training

• Hygiene

- Secondary prevention

• Information

• Education - Prevention

• Legislation

• Budget

• Substructures.

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Ankle Instability

Acute ligament lesions of the ankle are a common problem in sports trauma and in daily life. The incidence of ankle sprains in the community is 1/10,000 a day (Davis and Trevino). Even with appropriate treatment, some patients develop chronic instability with difficulties in sports activities and even in daily life. Ankle sprain, due to its high incidence among referees, deserves mention in this article. Ankle ligament lesions may be classified as:

- Type I – minor lesion;

- Type II – partial ligament rupture;

- Type III – total ligament rupture.

The deltoid ligament, responsible for medial stabilisation of the ankle, is damaged during an eversion/abduction movement. The anterior and posteri- or talofibular ligament and the calcaneofibular ligament are responsible for ankle stabilisation during inversion movement.

Diagnosis

After ankle sprain, it is important to understand the lesion mechanism in order to identify damaged structures. Local inflammatory signs, stress tests (inversion, eversion, and anterior posterior), and inspection can provide valu- able information for classification and diagnostic. They are sometimes of low sensitivity in the acute phase; however, they are useful for late evaluation of a sprain sequela. MRI may be of interest for diagnosis, showing which ligaments are damaged and to what extent.

Treatment

The objective of the treatment is to obtain a good functional result and avoid chronicle ankle instability. In the acute phase, all ankle sprains should be submitted to rest, ice (48 h), compression, and elevation. Types I and II lesions should be protected with a brace during the initial face, being accept- ed that early mobilisation is of advantage. In respect to type III lesions, most studies have shown that early mobilisation followed by a period of physiotherapy with neuromuscular training achieves good results, even superior to surgical treatment. On the other hand, ligament reconstruction can always be performed secondarily, with results being similar to those achieved by primary surgical treatment. Surgical indications are as follow:

- Large osseous avulsion fragments;

- Severe ligament lesions;

- Recurrent type III lesions;

- Conjoint medial and lateral collateral ligament (LCL) lesions.

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Chronic Instability

Until recently, surgical treatment of chronic ankle instability was not effective in returning athletes to sports activities. In 1998, we conducted a study to evaluate the dimensions of the internal malleolus by tri-dimensional com- puted tomography (CT) scan in 30 cases. This study showed a significant rela- tion between a short medial malleolus, number and severity of sprains, chronic ankle instability, and osteoarthritis (p<0.05). Arthroscopic treatment with radiofrequency is nowadays a solution available for use by orthopaedic surgeons. This technique uses thermal shrinkage of the capsule and ligaments with molecular remodelling. We have been using this surgical approach in chronic ankle instability since 1999.

Materials and Methods

In our study, we used arthroscopy equipment with a 2.7-mm, RF generator Mitek and VAPR-T probe. From May 1999 to April 2003, we operated 98 ankles with chronic instability, including 3 referees. We selected those whose surgery was performed more than 12 months earlier and reviewed 88. There were 36 males and 52 females, with a mean age of 22 (14–45) years. The stress x-ray showed a mean external opening of 9.2º (5.4–21.9º). The mean number of sprains per year was 5 (4–12). The mean lesion duration was 5 (3–7) years. We selected patients with no improvement after 6 months of rehabilitation (with or without local corticoid injection), more than 4 sprains a year, pain on the LCL and external tilt difference from side to side >5º (TELOS). In this series, 51 patients performed sports activity and 37 patients were sedentary.

Postoperatively, ankles were protected with a brace for 6 weeks and a brace was used for more than 3 weeks. At 6 weeks, all the patients were submitted to physiotherapy with proprioceptive work and fibular muscles reinforcement.

Results

All patients were revised with clinical examination, the American Orthopaedic Foot and Ankle Society (AOFAS) score, and varus and anterior drawer stress x-ray. Mean follow-up was 42 (12–64) months). The external opening decreased more than 50%, and the mean number of sprains decreased from 5 to 0.2. All referees returned to their previous level of com- petition and would have the same surgery again. Overall results were:

- Preoperative AOFAS mean score: 58.2;

- Postoperative AOFAS mean score: 89.5;

- Average AOFAS increased 31.3 points;

- 75 patients would have the same surgery again.

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Relevance

Our results were good and promising. Ankle stability improved in all patients.

Even in those with an augmented external opening, the number of sprains and pain decreased. We found good and excellent results in 67% of patients in this series, and those results remained with time (mean follow-up 42 months). We believed that this technique has a place in the treatment of chronic ankle instability.

Conclusion

There are no references in the literature regarding referees lesions. It is important to encourage work in that area and to stimulate prospective studies among those professionals. There is no doubt that referees deserve atten- tion and careful care.

Referee Lesions J

Introduction

Muscle Injuries

Conclusion

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