Prevalent Orthopedic Injuries in Recreational Athletes after SARS-COV2 Lockdown: An Orthopedic Surgeon’s Point of View in Order to Help Sport’s Physicians Daily Practice

Abstract

The conditions of compulsory social isolation in the course of 2020 due to severe acute respiratory syndrome coronavirus 2 (SARS-COV2) have forced even the most active individual to reduce their level of training and/or acquire sedentary habits. The effects of confinement have caused disarrangement, reflected in the loss of physical fitness because of lack of or decrease in training and changes in diet and healthy lifestyle. It has also caused modifications in psychosocial plane. This review analyzes the most frequently seen orthopedic injuries in recreational sports athletes after lockdown: muscle injuries, tendinopathies, acute or stress fractures, medial tibial stress syndrome, sprains, dislocations, and fasciitis.

1. Introduction

Many recreational athletes who resumed their practice after a long period of detraining rejoined without noticing fatigue and discomfort, which precede the onset of pain. This situation, added to an incorrect periodization, graduation, and progression of workloads; inadequate nutrition and hydration; incorrect execution of the sports gesture with inappropriate movement patterns; and lack of rest and post-exercise recovery, generated a predisposition to suffer damage in some body tissues [1]. It should be noted that these situations occurred in stages prior to COVID-19 pandemic situation, but actually their prevalence has currently increased.

There are multiple variables that need to be addressed in order to recommend how to perform physical activities: type, frequency, intensity, duration, and density. There exist many guides related to this topic, but the special situation related to COVID-19 generated high interest aimed to avoid injuries after an extended period of untraining [1].

The epidemiological analysis of sports injuries started with Dr. Roald Bahr’s work. He described a methodological approach for the study of risk factors on sports injuries using Meeuwisse’s multifactorial dynamic model in 2003 [2, 3]. Subsequently, several guidelines follow one another in terms of prevention strategies: from the linear cause-effect postulates of Quatman et al. [4] to the interactive models of Mendiguchia et al. [5] and complex systems, which have become widely known today with their “web of determinants” or “neural network” [6]. Broadly speaking, these works allow us to distinguish:

1. Internal risk factors, specific to each individual, which in turn are divided into nonmodifiable (age, anatomy, sex, previous injury, etc.) and modifiable (flexibility, dexterity, body composition, aerobic capacity, strength, neuromuscular control, etc.). They act as predisposers;

2. External risk factors, which correspond to characteristics of the external environment (playing field, footwear, equipment, etc.);

3. Inciting event, which can appear as a game situation, position of a joint in the surface on the ground, inappropriate movement pattern, collision, fall, etc.;

4. Training load, which is the stimulus applied to obtain an adaptive response. It must be prescribed appropriately because excessive workloads will produce fatigue and negative physiological effects as well as insufficient ones. On the other hand, appropriate stimuli will improve physical fitness, causing a positive physiological adaptation to the stress that it produces.

This is a dynamic process, since all these factors are interrelated and interact in multiple ways [6].

Ideal athletes do not exist because they all have internal risk factors (Figure 1). The predisposed individual becomes susceptible when exposed to external risk factors. This fact, added to the application of a workload and the occurrence of an inciting event, can result in an adaptation to this stimulus or produce a failure/fatigue in the athlete’s biopsychomechanics, with consequent damage to the different tissues of the anatomy and/or the psychic apparatus.

Figure 1.

Modified from “How do training and competition workloads relate to injury? The workload-injury etiology model.”

Excessive workload will cause an injury. Athletes can return to play with previous rehabilitation or not recover from this event.

Appropriate workload will generate adaptation, and this situation may modify internal risk factors.

Almost every injury is suffered as a devastating experience for an athlete. However, there is a large amount of evidence regarding the most effective treatment options for a particular type of injury in order to achieve an adequate return to play. It is important to note that there are many variables to have in mind when determining a treatment. Many of these factors have not been considered in the systematic reviews that were taken as a reference in this article, which represents an important area of research to be developed. These limitations, the quality of evidence and patient preferences, must be included when determining an appropriate treatment.

The analysis of epidemiological data is essential to identify risk factors, sport-specific patterns, and injury mechanisms, allowing to propose in this way prevention strategies that range from the introduction of protective equipment to changes in regulations and the field of play among other possible interventions in order to reduce the athlete’s time out of training or competition. It will allow us to make effective decisions on preventive actions.

2. Muscle injuries

Muscle generates movement by contracting or relaxing. It makes up 40–45% of the total body mass. It is enveloped by fascia and attached to the skeleton by tendons. There are two types of muscle: striated (skeletal and cardiac) and smooth (found in the wall of hollow organs, for example). Its functional unit is the muscle fiber (or muscle cell), and there are two classes: red (type 1) and white (type 2) [7]. Type 1 fibers are slow-contracting fibers and resistant to fatigue, since they are located in postural muscles of the trunk (continuous activity). On the other hand, type 2 fibers are fast-contracting fibers, since they are located in upper and lower limbs.

Its functions include generating movement and mechanical energy (stored in glycogen), providing joint stability and protection to other deeper tissues, maintaining posture, and providing heat to the human body. It is an organ of greater adaptability since, being trainable, it can increase its strength and size [8]. It also has an endocrine function: acting on the brain (cognitive function), bone (mineralization), liver (carbohydrate metabolism), immune system (modulation), and adipose tissue (thermogenesis), among others [9].

Functional and structural muscle injuries [10] are produced by stretching too fast too far. Most of them are caused by noncontact situation: overload or overexertion [11]. They can also be generated by violent contraction against resistance or sudden uncoordinated and involuntary elongation. They are the most frequent injuries in athletes, and almost all of them occur at myotendinous junction [12]. It predominantly affects lower limbs (more frequently hamstrings). Modifiable risk factors can be identified: acceleration or deceleration movements, lack of warm-up and return to calm, muscle fatigue, large volume of training, and anabolic intake, among others. NOT modifiable risk factors include age older than 30 years, previous tear, biarticular muscles with type 2 fibers [13], etc. In order to diagnose muscle injuries, we recommend to start with a precise history of the occurrence, the circumstances, the symptoms, previous problems, followed by a careful clinical examination with inspection, palpation of the injured area, comparison to the other side, and testing of the function of the muscles. We will focus on structural muscle injuries in this review. There may be pain, functional disability or limitation (inability or decreased mobility of the affected area), local inflammation, hematoma, and sometimes audible “clicking.” On certain occasions, when a frank muscular rupture occurs, a “gap” (defect similar to sinking) can be observed in the affected surface. It is important to establish a correlation of having made an exertion with the body segment involved. Some imaging studies must be carried out to verify the injury. Broadly speaking, trained sonographers will have no trouble identifying them. But it should be noted that this is an operator-dependent procedure. On certain occasions, a magnetic resonance imaging (MRI) will be required to reach an accurate diagnosis [14]. There are countless muscle injuries classifications, but currently the one described by FC Barcelona-Aspetar [15] presents the greatest advantages due to its detailed analysis regarding the type of injury and high-performance treatment strategy. It refers to the extracellular matrix involvement. For practical purposes, we will combine O’Donoghue [16] (symptoms-based) and Takebayashi et al. [17] (ultrasound-based) classification, which describes the following three types:

• Grade I: normal architecture, no appreciable tissue tear.

• Grade II: partial rupture of muscle fibers, with reduced strength of musculotendinous unit.

• Grade III: total rupture and complete loss of function.

Treatment will be conservative in grades I and II and will follow the premises of POLICE rule [18]. “P” represents Protection. During the first 48 hours after the event occurred, the body weight will be unloaded (do not support the body segment involved). If lower limbs are affected, a pair of crutches may be used. “OL” implies starting gradually and progressively Optimal Loading. Quick mobilization prevents hypertrophic scars and avoids reposterior ruptures; that is why patients should start loading if they are able to. “I” stands for Ice, to be applied in periods of approximately 15–20 minutes, every 30 minutes. “C” refers to Compression, which can be applied with an elastic bandage, thigh, calf, etc. “E” symbolizes Elevation of the affected limb in order to reduce edema and consequently pain.

Rehabilitation will be in charge of physiotherapists and involves sequential strengthening protocols according to pain tolerance and progressive evolution of patient’s condition [15]. Regarding grade III injuries, surgical or conservative treatment will be considered according to age, functional limitation, affected region, occupation, activity level, etc. Complications consist of hypertrophic scars, fibrous nodules, myositis ossificans, and acute or stress compartment syndrome.

Prevention strategies include muscle eccentric training and strengthening, warm-up and cool-down practice, stretching, proprioception, correct technique, and avoiding muscle fatigue [15].

3. Tendinopathies

Tendons are connective tissue bands which insert muscle into bones. They transmit muscle contraction force to the bone in order to generate movement. Its relatively avascular structure implies a scarce regeneration process (producing nonelastic collagen fibers) if damage occurs [19]. Overuse causes repetitive microtrauma on the enthesis (insertion zone in the bone), exceeding self-intrinsic repair capacity [20]. It is important to highlight that these are NOT inflammatory changes. It produces local degenerative vascular and structural disorganization [21]. We also need to mention other causes of tendinopathy: rheumatological disorders (psoriasis, rheumatoid arthritis, etc.), metabolic diseases (gout, diabetes, hypercholesterolemia, etc.), and toxic (fluorinated) and pharmacological (statins) intake [22, 23, 24, 25].

According to Blazina’s classification, tendinopathies can cause pain at the end of sports practice (type I). It may start with the activity and disappear at the end of it (type II) or it could be permanent (type III). It can even cause tendon rupture (type IV). The most affected areas correspond to the medial and lateral elbow epicondyles (epicondylalgia), knee (patellar tendon), abdomen and pubis (groin pain—ex pubalgia), shoulder (subacromial compression syndrome—ex rotator cuff syndrome—most often affects supraspinatus muscle tendon), gluteal tendons, and the Achilles tendon.

Pain is the most important clinical feature. We can also identify local inflammation, decline in function or impotence, and reduced exercise tolerance. Sometimes, a clicking sound may occur if a rupture takes place. Tendinopathies develop gradually and progressively, although there may be cases of acute onset (especially type IV). Diagnosis is basically clinical, although images are sometimes required to rule out other associated injuries. Type I and II treatments consist of sports/work rest, after identifying the triggering-overloading repetitive action. Other alternative treatments include extracorporeal shock-wave therapy, nonsteroidal anti-inflammatory drug (NSAID) administration, kinesic therapies (Ciriax deep massage, eccentric exercises, etc.), platelet-rich plasma (PRP) injection, or 5% dextrose solution prolotherapy [26, 27]. Some type III injuries will be capable of nonsurgical treatments. In case it fails, tendinopathies will require surgery: longitudinal incisions, tenotomies, forage, or tendoscopy. Type IV injuries will be treated with tenorrhaphy or reinsertion.

4. Acute and stress fractures

Bone is a firm, hard, and resistant organ, which is part of vertebrate endoskeleton. It constitutes up to approximately 15% of the total body weight and is among the largest organs/systems of the human body [28]. Adult bone structure mainly includes cortical bone, cancellous bone (trabecular bone), and bone marrow cavity. Bone consists of three compartments: bone cells, extracellular organic matrix including collagen fibers and amorphous matrix, and extracellular minerals [29, 30]. There are three major types of cells in bone tissue: osteoblast (bone formation), osteoclast (bone resorption), and osteocytes (bone remodeling). Bone functions include supporting body movement, protection of internal organs, calcium storage, and blood cell production [29]. Recently, increasing studies have revealed that the skeleton contributes to whole body homeostasis and the maintenance of multiple important organs/systems, such as hematopoiesis, immune activity, energy metabolism, and brain function [31, 32].

Fracture is a loss of continuity in the cortical surface of the bone. Plastic deformity is more frequently seen in pediatric population since bone has a lower elasticity modulus. Fractures are produced by direct trauma (impact on the affected area), indirect trauma (at a distance from the region involved by transmission of forces), stress (repetitive microtraumas), or pre-existing pathologies (bone tumors, metastases, osteoporosis, etc.).

Symptoms include pain, local swelling, deformity or shortening, hematoma, functional limitation, or impotence. Sometimes, an audible click can take place. Exposed fractures show a skin wound in direct communication with the inside fracture site. Acute fractures have a clear traumatic history.

Stress fractures are produced by mechanical overuse in a prolonged period of time and account for 10% of all overuse sports injuries [33]. They will show progressive pain, without a clear onset. Bone tissue damage alternates with periods of remodeling, which causes a delay in the origin of symptoms. A complete cycle of bone turnover requires 3–4 months. When bone cannot remodel at the pace at which loading increases, it fractures [34]. Running is the most commonly associated sport—accounting for 69% of stress fractures [35]. Almost 95% occur in lower extremities due to the dissipation of ground reaction forces during load-bearing tasks such as marching, walking, running, or jumping [35]. Stress fractures typically occur in cortical bone in the following areas, in decreasing order of incidence: tibia, tarsal bones, metatarsals, femur, fibula, and pelvis [36, 37].

The diagnosis of acute fractures is made with simple frontal and profile radiographs (obliquely is demanded in distal regions: hands and feet). If there is a clear suspicion with a traumatic history and negative X-rays, sometimes computed tomography (CT) scan is requested. Periosteal reaction or continuity solution will be observed in one or both cortical surfaces. We can also use MRI, which will identify bone edema. Stress fractures will be diagnosed with these procedures or performing bone scintigraphy.

Treatment will be based on age, existence or not of bone exposure, affected bone, associated injuries, and functional demand of the patient, among other aspects. Broadly speaking, proximal and distal joint involving affected bone must be immobilized. POLICE rule will be applied according to tolerance. In other cases, surgical resolution will be chosen (reduction and osteosynthesis, osteodesis, arthroplasty, vertebroplasty, or arthrodesis, as appropriate). Exposed fracture constitutes a traumatic emergency and must be resolved in the operating room. Treatment will include washing and debridement of the wound, attempting to cover the exposure, stabilization of the fracture, antibiotic therapy, and tetanus prophylaxis. Stress fracture treatment should be analyzed in each particular case depending on the bone and affected area thereof, activity level of the patient, age, whether or not there is articular cartilage involvement, etc.

5. Medial tibial stress syndrome (MTSS)

Medial tibial stress syndrome is the most frequent overuse injury in runners and athletes involved in jumping. Incidences varying from 4–35% are reported, with both extremes being derived from military studies [38, 39, 40]. Clinically, it shows pain in posteromedial side of the mid- to distal tibia over a length of at least 5 cm during or some time after training [41, 42]. From the literature, it is unclear as to whether tibial stress fracture is a continuum of MTSS. In the 1970s, Roub et al. were the first to suggest that increased levels of stress to the tibia could result in a spectrum of bony overload. In this spectrum, the end stage was a cortical fracture. In the beginning of this spectrum, when bone resorption outpaces bone formation and replacement of the tibal cortex, MTSS occurs [43]. Differential diagnoses include nerve compressions, vascular pathologies, exertional compartment syndrome, and tibial stress fracture, among others [41]. Differentiation can usually be accomplished without additional imaging. Bone scintigraphy and magnetic resonance imaging (MRI) are widely used to confirm the diagnosis [44]. Treatment will follow POLICE rule guidelines. Rest and not supporting body weight is the most important advice.

6. Sprains

Ligaments are bands of elastic, fibrous connective tissue which hold bones together. Its function is to maintain “controlled mobility” of joints, giving passive stability, facilitating, and restricting certain actions. In addition, they give proprioceptive sensitivity to the involved joint. Sprain is considered a transitory loss of relations in an articular surface due to an overstretched ligament injury. Typically, a traumatic mechanism causes the ligament to stretch beyond its normal range, leading to injury. Ankle is the most frequently affected area in athletes.

Due to their clinical relevance in sports, we must mention knee injuries: anterior, posterior, lateral internal, and external cruciate ligament sprain or rupture, which can also be associated with meniscal injuries.

Ankle sprains manifest with pain, local inflammation, hematoma, impotence or functional limitation, clicking, feeling of instability, and intolerance to load. They are considered acute injuries. 78% of ankle sprains are caused by plantar inversion and flexion, a mechanism that usually affects the external lateral ligament (most frequently the anterior talofibular ligament).

Differential diagnosis should be made with other injuries that reproduce the same symptoms but are more serious, so radiographic images will be requested, thus excluding fractures and/or dislocations. On certain occasions, it will be necessary to request MRI to rule out soft tissue injuries: peroneal tendons, syndesmosis, deltoid ligament, etc. According to symptoms, we can classify sprains into three types: (1) mild, (2) moderate, and (3) severe. Type 1 is characterized by ligament elongation (sprain) without rupture, little or no functional limitation, mild edema, and joint pain and stability. In contrast, type 3 manifests with great functional impotence, hematoma, edema, pain, and instability due to total ligament rupture accompanied by joint capsule injury [45]. Treatment in mild grades of nonsports patients with stable ankle consists of applying POLICE rule for a 4–5-day period using a walker-type boot during 10 days, followed by gradual and progressive mobility according to tolerance for 2–3 weeks [46]. Currently, there is controversy regarding the treatment of type 3 sprains in high-performance athletes [45, 47]. Approximately 30% of ankle sprains are known to evolve into chronic instability, characterized by mobility greater than the functional limit, pain, edema and swelling, recurrent sprains, and the inability to perform physical activity. Treatment consists of performing proprioception exercises and strengthening peroneal muscles for a 6-week period. Faced with therapeutic failure, we proceed to surgical resolution.

7. Dislocations

Joints are areas where two or more bones join each other. They are classified into synarthrosis (immobile), amphiarthrosis (semimobile), and diarthrosis (mobile). In turn, diarthroses are subdivided into enarthrosis, condylarthrosis, troclearthrosis, reciprocal socket, trochoids, and arthrodesis. Dislocation is considered the loss of permanent contact of the articular surfaces, unlike sprain, which is characterized by being transitory. It can be caused by direct or indirect trauma. Clinically, pain, deformity, hematoma, edema, and inflammation associated with impotence or functional limitation can be observed. Diagnosis is established by X-ray (at least two projections: front and profile) where we will observe the “uncoupling” of involved bones. Associated injuries must also be ruled out. Treatment consists of performing reduction under anesthesia in the operating room. It constitutes an orthopedic emergency. Affected joint will be immobilized after evaluating post-reduction joint stability. In a second time, complementary studies may be requested to verify the indemnity or not of joint stabilizers. The most frequently affected joint in general population is the shoulder.

8. Fasciitis

Fascia is a connective tissue membrane that lines the muscles. In the plantar region, this structure is arranged from the base of the heel to the toes forming a wide band. Plantar fasciitis is the most common cause of heel pain, accounting for 80–90% of all cases. It is a chronic condition caused by traction on its insertion in the calcaneus bone. Sometimes, pain radiates toward the fingers. Its etiology remains unknown. Symptoms usually appear gradually and progressively after prolonged rest, can be established acutely, manifest during training, or be triggered by just walking or prolonged standing, in the most severe cases. A third part of all cases are bilateral. Plantar fasciitis is characterized by the exacerbation of pain on passive dorsiflexion of the fingers and forefoot, since this maneuver tightens the fascia. It can also be associated with morning stiffness. Diagnosis is made with the clinical examination. On certain occasions, images are needed both to rule out other pathologies and to confirm this condition. Treatment strategies include the use of NSAIDs, heel pads/insoles, night splints, and kinesic therapy based on stretching exercises and shock waves. In the case of nonsurgical treatment failure, open or arthroscopic fasciotomy will be performed.

9. Conclusions

Sports injuries lie in three fundamental aspects and their interrelationships: risk factors, inciting event, and work training load.

Gradual and progressive return to physical activity is recommended after a prolonged time of detraining in order to avoid injuries. Exercise must be performed in a structured and repetitive manner (at least at the beginning) through strength and/or resistance training.

Strength training should be performed using around 50% percent of maximum repetition (MR, three concentric and three eccentric with no rest in between). This planning produces the same benefits than training with 80% of MR (one concentric set, one eccentric set, and a rest set between them) and does not involve any specific equipment [48]. Exercises can be done with your own body weight, elastic bands, etc. Therefore, low-intensity and high-volume plans (lower loads and multiple repetitions) are preferred [49].

Resistance training must involve large muscle groups, such as jumping rope, jogging in place, burpees, and mountain climber.

Ideally, people can work in circuits doing quick repetition series, combining both strength and resistance training. It allows us to modify a number of circuits, series, and speed of execution [48].

Physical activity recommendation guidelines [50, 51] suggest 150–300 minutes per week of resistance training at moderate intensity (allows people to speak, but not sing) or vigorous (75–150 minutes per week, reaching that magnitude when only a few words can be told while performing training). Two or three muscle strength training sessions must be performed per week.

Coordination and balance should also be considered. Warm-up programs decrease injury rates by 30%. They include activities that increase body temperature and thus prepare tissues for maximum effort.

Static stretching exercises maintain body parts in a fixed position in order to relax certain muscles passively for at least 10–25 seconds. It improves flexibility and range of motion. Cooldown is also recommended when finishing.

If pain appears and/or remains (or even increases) in a period of 24 hours post-exercise, “too much too soon” could be the reason. Correct technique with proper movement patterns should always be executed before adding workload. A weekly increase in workload should not exceed 10%, since values above it contribute to injuries [52].

There is a better response to small increases (or decreases) in workload than to larger fluctuations on it.

Finally, you should have in mind that proper rest and recovery are essential part in training.