Sports injury prevention and overuse injuries — formative SAQs

SAQ 1 (10 marks) — The thirteen-year-old with knee pain

Stem: A thirteen-year-old boy who plays basketball for his school, a club team and a representative squad presents with six weeks of gradually worsening pain over the front of his right knee that comes on with jumping and eases with rest. He trains about twenty hours a week. On examination there is no effusion and no limp, the pain is reproduced by pressing over the bony bump below the kneecap, and resisted knee extension reproduces the discomfort. Outline the diagnosis, the injury mechanism, your assessment of the risk factors, and your management. [2] [7]

Model answer

Diagnosis and mechanism (3 marks). This is Osgood-Schlatter disease, a traction apophysitis at the tibial tubercle where the patellar tendon inserts. The mechanism is repetitive submaximal load applied faster than the growing apophysis can remodel, producing cumulative microdamage at the cartilaginous apophysis that fails before the adult tendon or bone would. It is an overuse, or microtrauma, injury rather than an acute macrotrauma, and the gradual onset, the activity-related pain relieved by rest, the focal tenderness over the tubercle, and the absence of an effusion or a limp all fit. [7] [2]

Assessment of risk factors (3 marks). I screen the validated injury-risk triad of sport specialization, high training volume and inadequate recovery. He specialises in one sport across three teams, trains around twenty hours a week (more than his age, a recognised volume threshold), and the organised hours exceed twice his free-play hours, so the triad is strongly positive. I take a training history for rest days, a recent load spike and a growth spurt, and I screen for the red flags that would move him off the simple-apophysitis pathway: night pain, a limp, focal bony tenderness elsewhere, weight loss, and any sign of relative energy deficiency in sport. This boy has none of these. [1] [2]

Management (4 marks). The principle is relative rest, meaning modification of the aggravating activities to a pain-tolerable level while keeping the limb active, not immobilisation or cessation of all sport. I apply ice after activity, teach a quadriceps and hamstring stretching and strengthening programme, and advise a graded return to play that progresses as his pain allows. I address the cause by reviewing his training hours and his three-team schedule with him, his family and his coaches, and I counsel against early sport specialisation and for at least one to two rest days each week and two to three months away from the specialised sport each year. I give a clear safety-net to return if night pain, a limp, or focal bony tenderness emerge, and I explain that the condition resolves as the apophysis fuses at skeletal maturity. [7] [1]

SAQ 2 (10 marks) — The runner with shin pain and lost periods

Stem: A fifteen-year-old competitive distance runner presents with three months of right shin pain that now hurts at night and on walking. She has lost four kilograms, her periods stopped six months ago, and she runs sixty kilometres a week. Examination shows focal bony tenderness over the mid-tibia. Outline your assessment, the differential, the investigation, and your management. [5] [9]

Model answer

Assessment and the red flags (3 marks). This is not a simple overuse injury. The red flags are present in combination: night pain, pain on walking, focal bony tenderness over the tibia, weight loss, and loss of menses. The combination of high training load, weight loss and amenorrhoea points to relative energy deficiency in sport as the driver, and the focal tender tibia with night pain points to a bone stress injury or stress fracture. I take a full training, nutritional and menstrual history, ask about eating attitudes and behaviours, and examine for focal tenderness, a limp, and signs of the low-energy-availability syndrome. [5] [9]

Differential and investigation (4 marks). The leading diagnosis is a tibial stress fracture on the background of relative energy deficiency in sport with low bone mineral density. The differential includes a tibial stress reaction short of fracture, a medial tibial stress syndrome that does not cause night pain or focal tenderness, and, less commonly, an osteoid osteoma or a malignancy, which the focal pain and night symptoms force into the differential. I arrange a radiograph first, recognising that early stress fractures are often invisible on plain film, and I proceed to MRI, which shows the stress injury earlier and grades its severity. I check bone mineral density by dual-energy x-ray absorptiometry with paediatric reference values, and I screen the energy-availability, hormonal and nutritional picture with the relevant bloods, framed with the multidisciplinary team. [9] [5]

Management (3 marks). I restrict load and refer to the sports-medicine and the multidisciplinary team. The bone stress injury is managed with a period of protected weight-bearing or, for a higher-risk site, non-weight-bearing, guided by the MRI grade and the site, with a graded return only when the pain-free interval is sustained. The driver is addressed directly: a multidisciplinary plan for relative energy deficiency in sport that restores energy availability through nutrition and load reduction, addresses the menstrual disturbance, and protects bone mineral density, with the physician, the dietitian, the physiotherapist and a mental-health clinician. I do not return her to running until the energy availability, the menstrual function and the bone are on a safe trajectory, and I communicate the plan with the family, the coach and the school. [5] [9]