Ab

Figure 41-8 A, Radiograph of a proximal phalanx fracture. B, Radiograph after reduction. thus creating ice cream on the tip of a cone effect. Intraarticular fractures that are nondisplaced (< 1mm) or minimally displaced dorsal or volar chip avulsions may be treated with splinting and early ROM. Radiographs must be checked frequently to ensure that there has been no change in the fracture position.28 Surgical indications include displacement of the joint surface of greater than 3 mm, fractures...

Achilles Tendon Rupture

Achilles tendon ruptures occur most commonly during sports. There is a male predominance occurring in the third to fifth decades. The mechanism is frequently push-off occurring during sprinting and jumping sports resulting in violent ankle dorsiflexion. The patient often describes a sensation of being kicked in the calf or heel. The patient's calf and Achilles tendon should be palpated for continuity. Ecchymosis and swelling should be noted. The Thompson test should be done by placing the...

Alpha Agonists

Phenylpropanolamine and pseudoephedrine, both alpha agonists, are commonly found in over-the-counter medications and known for their stimulant effects. In fact, since the U.S. Food and Drug Administration banned dietary supplements containing ephedrine, many manufacturers have replaced ephedrine with a variety of alpha agonist compounds. Numerous studies of the effects of phenylpropanolamine and pseudoephedrine on aerobic and anaerobic exercise have failed to show ergogenic benefits, with no...

Anterior Drawer Test

After an ankle sprain, the anterior drawer test is used to evaluate the integrity of the ATFL and, to a lesser extent, the CFL. It is most useful in cases of suspected chronic ankle instability. Brostrom7 showed that this test's sensitivity was relatively low in the acute setting secondary to guarding. First, have the patient relax the affected extremity with the knee flexed. Then, stabi- Figure 65-8 Thompson test. Absent or diminished plantarflexion indicates Achilles tendon rupture. Figure...

Apophyseal Avulsion Injuries

An apophyseal avulsion fracture of the pelvis is a fracture through the physis of a secondary center of ossification. These commonly involve the anterior superior iliac spine, anterior inferior iliac spine, and ischial tuberosity apophysis. These fractures occur almost exclusively in 11- to 17-year-old patients. They are most commonly seen in soccer, track, football, and baseball. In most cases, these fractures occur during fast running, hurdling, pitching, or sprinting.15 These injuries...

B

Figure 11-3 A, Neuromuscular electrical stimulation (300PV Empi Inc., St. Paul, MN) of the infraspinatus during external rotation isometric exercise. B, Neuromuscular electrical stimulation (300PV, Empi Inc.) of the quadriceps during isometric quadriceps setting exercise. C, Biofeedback (Pathway MR-20, Prometheus Group, Dover, NH) on the vastus medialis obliquus and vastus lateralis during isometric quadriceps setting exercise to allow the patient to monitor the amount of muscle activity.

Biceps Tendon Pathology Nonanchor Related

If the presenting complaint is pain at the front of the shoulder, especially if the point of maximal tenderness is reproduced with palpation in the area of the biceps tendon as described previously, a biceps tendon problem should be considered. Although the biceps tendon is normally difficult to palpate, there are a number of provocative maneuvers that can be considered to help confirm or rule out biceps tendon pathology. It should be remembered that many of these signs coexist with subacromial...

Bony Impingement

Most patients with anterior bony impingement in the ankle will present with anterior ankle pain and loss of dorsiflexion. Soccer players seem to be particularly prone to this problem due to the repetitive trauma to the anterior capsule. Dancers and runners develop anterior bony impingement because of repetitive dorsi-flexion. The pain and loss of motion may worsen slowly over time, but presentation to a physician is often precipitated by an acute injury.1 The diagnosis can be confirmed with...

Boutonniere Injuries

Boutonniere injury involves rupture of the central slip of the extensor mechanism at its insertion into the base of the MP. Injuries may be due to either direct trauma to the dorsum of the PIP joint or an acute flexion force applied to the PIP joint with opposed active extension. The term boutonniere is derived from the French word for buttonhole, which refers to a split that occurs in the dorsal covering of the PIP joint where the central slip of the extensor mechanism avulses from its...

Caffeine

Caffeine is perhaps the most popular stimulant used by the general population. Prior to the U.S. Food and Drug Administration ban on products containing ephedrine, products combining caffeine and ephedrine were among the most purchased dietary supplements and weight-control compounds. Accordingly, much of the research into the ergogenic properties of caffeine actually studies combinations of caffeine and ephedrine. With regard to caffeine alone, caffeine is thought to be most beneficial for...

Carl J Basamania Elizabeth G Matzkin and George K

Plate fixation Intramedullary fixation Sternoclavicular joint disorders Degenerative conditions Atraumatic subluxation dislocation Traumatic injury dislocation Surgery sternoclavicular (S-C) reconstruction Displaced fractures of the clavicle are easily diagnosed if the patient is seen soon after injury. Patients usually present with an obvious clinical deformity and a consistent history of some form of direct or indirect injury to the shoulder. The proximal frag ment is commonly displaced...

Cervical Disk Herniations

Cervical disk injuries occur with higher frequency in highperformance athletes playing football or wrestling than the general population.3 Cervical disk disease is generally categorized into soft versus hard disk disease. Acute disk herniations in sports are thought to occur from uncontrolled lateral bending3 (Fig. 15-4). Hard disk disease (disco-osteophytic disease) can become symptomatic through various mechanisms (Fig. 15-5). Both entities can cause varying amounts of neck and arm pain....

Cervical Stenosis

The diagnosis, management, interpretation, and implications of cervical stenosis have caused significant debate and controversy over the past several decades. The concept of cervical stenosis is simple the spinal canal is narrow. However, the answer to the question of how narrow is too narrow is quite complex. Abnormal angle 20 _(-4) 24 > 110 Figure 15-2 Radiographic assessment of cervical spine alignment. A, The anterior vertebral line, posterior vertebral line, spinolaminar line, and...

Chief Complaint

A complete understanding of the chief complaint is critical to arriving at the correct diagnosis. This cannot be overemphasized due to the multiple pathologies in the shoulder of the throwing and overhead athlete. An operative shotgun approach to the wrong problems can end such an athlete's career, as more surgery that is undertaken in these patients lowers the chances of returning to high levels of participation. These overlapping pathologies present the so-called athlete's dilemma,...

Chief Complaint Loss Of Control Andor Velocity

When a patient presents with this complaint, the initial differential should include dynamic instability often associated with SLAP tears and internal impingement as well as muscle weakness and scapular dyskinesia. Throwing is an extremely complex athletic maneuver and relies on the specific coordination of the entire kinetic chain. This chief complaint is often among the most difficult to discern because, by its nature, it implies that the athlete is able to throw, and thus the impediment is...

Chief Complaint Numbness Or Tinglingparesthesias

There are a number of conditions that may lead the athlete to seek treatment for numbness or tingling. If one rules out the possible cervical pathologies discussed previously, then the initial differential should concentrate on sources of peripheral nerve compression. The pertinent sources include thoracic outlet syn drome, burners, and brachial neuritis. If distal in the arm, com pression of the median and ulnar nerves may also be considered. Thoracic outlet syndrome is an uncommon, but...

Chief Complaint Pain

Perhaps no chief complaint is as common as pain in the shoulder and none with a broader list of possible causes. Many of these causes overlap or play a role in the pathology of other processes. In addition, there is often more than one source of pain in the overhead athlete, making the approach not nearly as clear as one would like.2 We begin with pain, describe the differential, and endeavor to describe how to narrow down the list to a few diagnoses to test on physical examination. A list of...

Chief Complaint Stiffness

True stiffness, defined as a mechanical block to passive motion, can present with or without pain and can be global or in selected motions. In most athletes, stiffness occurs in the presence of a painful shoulder. When stiffness does coincide with pain, the reader is directed to the pain as chief complaint section, as diagnosis and treatment of the pain source will often lead to resolution of the stiffness. Occasionally, stiffness can contribute to pain, especially in the throwing athlete. One...

Christopher C Dodson and Riley J Williams III

Surgery pectoralis repair Subcapularis rupture The pectoralis major is a triangle-shaped muscle that arises from the clavicle, sternum, ribs, and external oblique fascia (Fig. 301). The muscle has two heads clavicular and sternal. As these various origins converge to their insertion at the lateral aspect of the bicipital groove, the muscle twists. Ultimately, the superior fibers insert distally and the inferior fibers insert proximally. These fibers terminate in a flat tendon that is...

Chronic Exertional Compartment Syndrome

Chronic exertional compartment syndrome has symptoms similar to those of the acute entity but to a lesser degree and is a more difficult diagnosis to make. Patients typically complain of aching pain or paresthesias (and occasionally vascular complaints) after exercises that stress or challenge the leg muscles.25 Runners complain of insidious pain that begins to limit their activity level. Symptoms originate after beginning activity, and typically resolve after 10 to 30 minutes upon completing...

Chronic Medial Collateral Ligament Reconstruction

Medial Collateral Ligament Repair

In cases in which the patient is first seen 3 weeks or more after the injury, it is probably too late to treat grade III MCL injuries successfully with either open primary repair or closed conservative management. In reviewing the literature, there are multiple ways to attempt to reconstruct the MCL. This usually means that there is no one procedure available that is always successful. In past years, the senior author reconstructed the MCL mainly by detaching its proximal end and either...

Classification of Cerebral Concussion

Occasionally, players sustain a blow to the head resulting in a stunned confusional state that resolves within minutes. The colloquial term ding is often used to describe this initial state. However, the use of this term is not recommended because this stunned confusional state is still considered a concussion resulting in symptoms, although only very short in duration, which should not be dismissed in a cavalier fashion.1 It is essential that this injury be reevaluated frequently to determine...

Clinical Features

Shoulder pain secondary to biceps tendon pathology can be quite severe, causing significant disability. Often the exact etiology of the pain is not clear, as the pathogenesis of biceps ten-donopathy is intimately related to existence of other shoulder disorders. Yamaguchi and Bendra10 classified three major groups of pathologic processes in order to help describe and manage biceps disorders inflammatory, instability, and traumatic. This classification system was designed to characterize the...

Clinical Features And Evaluation

The majority of patients do not recall an inciting event, but patients should be queried regarding a posteriorly directed force, which can occur with a fall on an outstretched arm or during athletic activity. The most common complaint at presentation is pain with activity. Symptoms are often vague and are generally not localized to the posterior aspect of the shoulder. Chronic subluxation episodes lead to pain secondary to inflammation of the capsule, rotator cuff, and or biceps tendon.4,5 Many...

Combined Cruciate Reconstruction

We use a single-stage arthroscopic combined ACL PCL reconstruction using a bone-patellar tendon-bone allograft for the ACL and an Achilles tendon allograft via a transtibial approach for the PCL. The patient is positioned supine with the operative leg in an arthroscopic leg holder and the well leg widely abducted in the lithotomy position. A tourniquet is applied and used if visualization is impaired. A fluid pump is used judiciously with regular examination for fluid extravasation. Diagnostic...

Complex Ligamentous Conditions

The patient with instability related to multiple ligament capsule injuries is a great challenge for surgeon and therapist as outlined in a previous chapter. Certain combinations, such as ACL or PCL with posterolateral injury require surgical intervention, which make rehabilitation more difficult as the required early postoperative ROM limitations may provide a challenge to normalizing the ROM long term. Ambulatory abnormalities are often seen in these patients as they may have adopted a varus...

Complications

The most significant, yet uncommon, complication associated with muscle contusion is myositis ossificans, also referred to as myositis ossificans traumatica or post-traumatic ectopic calcifi- Risk Factors Five factors have been described for the development of myositis ossificans after contusion by Ryan et al.38 These authors determined that range of motion less than 120 degrees at classification, participation in football, history of a contusion injury to the same site, sympathetic knee...

Conclusion

PCL injuries, although less common than ACL injuries, may be seen in variety of clinical settings. These can usually be diagnosed by the skilled physician through a thorough physical examination and confirmatory radiographic studies. Low-grade, isolated PCL injuries are usually treated nonoperatively with acceptable outcomes. Recent studies, however, suggest that chronic PCL deficiency may lead to progressive joint degeneration and arthritis. Multiple surgical options exist for reconstruction...

Conclusions

Internal impingement is pathologic contact of the posterosupe-rior rotator cuff against the posterior glenoid labrum in the maximal abducted externally rotated position. Overhead athletes often present with loss of ability to perform due to early fatigue and posterior shoulder pain, previously known as dead arm syndrome. Symptoms usually occur during the late cocking and acceleration phases of the throwing motion or tennis serve. Clinical examination and diagnostic studies most often...

Contusion of the Anterior Tibia

Rarely, blows to the tibia may cause a fracture. Much more commonly, these contusions cause a painful soft-tissue injury. This type of injury is seen in youth soccer or sports in which direct blows to the subcutaneous border of the anterior tibia causes hematoma formation. If the hematoma is subperiosteal, it causes severe pain and may result in a significant bony prominence in that area as it consolidates. The use of shin guards for soccer serves to almost eliminate this unless the shin guards...

Diagnostic Arthroscopy of the Ankle

Patient positioning is usually based on surgeon preference. Patients can be placed in a supine position with the leg supported on the table or the leg can be placed in a leg holder and allowed to fall free. Some surgeons use the lateral decubitus position with the patient supported on a beanbag, and some surgeons recommend the prone position when the primary pathology is posterior and posterior portals are planned15 (Fig. 67-5). A standard 4.0-mm 30-degree arthroscope is usually sufficient, but...

Direct Muscle Injury

The aforementioned disorders share an indirect mechanism of injury, primarily eccentric loading. The final portion of this chapter deals with direct muscle injuries, which primarily present as lacerations and contusions. It is beyond the scope of this chapter to discuss lacerations, and readers are referred to general trauma texts. In cases of closed transactions of the biceps brachii muscle, surgical repair has been described with good results.32 This injury is uncommon and affects the unique...

Dislocation and Subluxation

Acute dislocation or subluxation of the peroneal tendons is an uncommon injury that has a traumatic cause. Sport participation is responsible for about 92 of acute peroneal dislocations. Skiing has been reported to cause approximately 66 of the sports injuries.10 Peroneal tendon dislocation may be difficult to distinguish from an acute ankle sprain, but it is rare for both to occur simultaneously. The acute dislocation is caused by a sudden forceful dorsiflexion with simultaneous violent reflex...

Dislocation or Subluxation

Acute Operative management is considered in the young athletic population. There is a high failure rate of conservative treatment and a better success rate with surgery. Superior peroneal retinacular repair will address acute subluxation or dislocation. The patient can be placed in a prone, lateral, or supine position we use the lateral position. A 7-cm longitudinal incision, 1 cm posterior to the fibula and following the tendons, is used. The sural nerve is identified and protected. The...

Dr John Bergfeld

Bergfeld distinguished himself on the playing fields and developed his love of sports medicine while an offensive lineman at Bucknell University. He did his internship and residency at the Cleveland Clinic Foundation and subsequently served as the team physician at the Naval Academy where he honed his skills along with another well-known sports medicine team physician, Dr. Bill Clancy. He subsequently served for more than 25 years as the Cleveland Browns team physician (Fig. 1-2) and was...

E

Figure 40-5 cont'd E, Diagram of a positive test. Figure 40-6 Radiographic findings of scapholunate injury on a pos-teroanterior radiograph. Scapholunate interval of 3 mm or greater (white arrow). Flexed scaphoid appears as a cortical ring (black arrows). Figure 40-6 Radiographic findings of scapholunate injury on a pos-teroanterior radiograph. Scapholunate interval of 3 mm or greater (white arrow). Flexed scaphoid appears as a cortical ring (black arrows). Figure 40-7 Radiographic findings of...

Establishing Reasonable Goals

Being goal oriented, both types of athletes are highly motivated to improve the skills and speeds that lead to better scores. This focus on goal achievement can be harnessed in rehabilitation if the physician, sports medicine therapist, and athlete work together and are creative in their approach to the healing process. Goals give the athlete something concrete to work toward and require his or her active engagement in the rehabilitation process. It is important that these goals be achievable....

Examination of the Shoulder for Laxity and Instability

With laxity testing, it is important that the patient be as relaxed as possible. We use a consistent grading system (described later) and ask the patient whether he or she can appreciate the trans-lation.5 We then ask whether the translation reproduces the symptoms. It is important to note that although we use these tests primarily for laxity, grinding, clicking, or pain may represent labral tears or chondral defects. Apprehension Test This test is performed with the patient either supine...

Fifth Metatarsal Fractures

Injuries to the base of the fifth metatarsal are common in athletes and are often due to an inversion force combined with the resistance of strong ligamentous structures.1 These fractures are termed avulsion fractures and usually involve the proximal 1 to 1.5 cm of the fifth metatarsal metaphysis. This area of the bone has been termed the tuberosity. These are considered type 1 fractures.2 Type 1 fractures are usually nondisplaced and are generally extra-articular. Patients present with a...

Forefoot

In the forefoot, palpate the metatarsal heads and necks for excessive tenderness to diagnose lesser metatarsal overload (as may occur after bunion surgery) or metatarsal stress fractures, respectively. The pain from an interdigital neuroma (i.e., Morton's neuroma) is similar in location but localized specifically between metatarsal heads, most often the third interspace. Mediolateral compression of the metatarsal heads may produce a click (Mulder's click) and generally reproduces the pain of a...

Frostbite

Frostbite is a localized lesion of the skin, predominantly of the periphery, caused by the direct effects of cold exposure. Enough heat is lost from the area that ice crystals are allowed to form in the tissues.29 Most commonly affected are the feet and lower extremities, accounting for 57 of injuries. Also common are injuries of the hands (46 ) and exposed areas of the face such as the nose, ears, and cheeks (17 ).30 Historically, frostbite has had its highest prevalence during military...

Functional Deficits

Athletes who participate in running, jumping, and cutting sports are at risk of foot and ankle injuries, particularly lateral ankle sprains. Ankle injuries are responsible for more than 25 of time lost from sports participation, may develop into a chronic disability in up to 30 to 40 of cases, and have an injury recurrence rate as high as 80 .1,2 Distal syndesmosis or high ankle sprains account for between 10 and 20 of all ankle sprains with considerably more disability and a greater loss of...

Hamstring Strain

Hamstring strains are most commonly seen13 and especially occur in those sports requiring sprinting or jumping. These muscles (long head of the biceps femoris, semimembranosus, semitendinosus) cross two joints so they are susceptible to fast, heavy loads. Strain location can be an avulsion at the origin on the ischial tuberosity. A mid-substance muscular strain is occasionally seen, but failure is most commonly at the musculo-tendinous junction, at the junction of the middle and distal thigh....

History And Physical Examination

The key to a proper history and physical examination is to have a standardized plan that accomplishes the needed specific objectives. Use a scale value of pain, function, and occupation to understand how sick the patient is. Converse in detail with the patient to hear the inflections and manner of pain description. Detail the time of disability and the time of origin of the pain. Know what psychological effect the pain has had on the patient. Know the social, economic, and legal results of the...

Human Growth Hormone

Human growth hormone (HGH) has been approved for treatment of persons with endogenous HGH deficiency or short stature secondary to chronic renal failure. Additionally, HGH is used off label for patients with Turner's syndrome and children born small for gestational age who have not had sufficient catchup growth.118 However, because of its success in treating these conditions, the abuse of HGH as an ergogenic aid has become widespread as well. In a survey of high school sophomores, Rickert et...

Hypertrophic Cardiomyopathy Pathology

HCM is a condition characterized by marked LV hypertrophy (LVH) with asymmetrical hypertrophy of the interventricular septum when compared to the posterior free wall. In approxi- Table 4-2 Pathologic Features of Hypertrophic Cardiomyopathy Left ventricular hypertrophy Asymmetrical septal hypertrophy Systolic anterior motion of the septal leaflet of the mitral valve Myofibrillar disarray Table 4-3 Historical Features Deserving Aggressive Evaluation Family history of sudden death at an early age...

Hypothermia

The classic definition of hypothermia is a decrease in core body temperature to less than 35oC (95oF). This develops when the rate of heat loss in an individual exceeds the rate at which the body can produce heat24 and when the ambient temperature is less than the body's core temperature.8 Classification is based on both cause and clinical severity. Primary, or accidental, hypothermia is what occurs in an otherwise healthy individual and is simply due to environmental exposure. Secondary...

Imaging Of The Cervical Spine

Imaging of the cervical spine has been a topic of considerable debate in the athlete. The favorable natural history of neck pain and the high incidence of false-positive findings should temper the use of advanced imaging. Gore et al13 demonstrated that 95 of asymptomatic male and 75 of asymptomatic female subjects had evidence of degenerative changes on plain films by the age of 65. Friedenberg and Miller14 showed that 25 of men andwomen have degenerative changes of the cervical spine by the...

Implants

These refer to materials left in situ to maintain the repair. For arthroscopic shoulder surgery, these include suture and suture anchors. Most suture that we use is nonabsorbable, braided multifilament suture. Generally, no. 2 suture is used for rotator cuff repairs and 2-0 suture is used for labral repairs. Some new suture types such as FiberWire (Arthrex, Naples, FL) confer greater failure strength. Capsular plications may also be done with no. 1 or 0 polydiaxone suture. Anchors are either...

Initial Onsite Assessment

Your approach to the initial assessment may differ depending whether you are dealing with an athlete-down or ambulatory condition. Athlete-down conditions are signified by the athletic trainer and or team physician responding to the athlete on the field or court. Ambulatory conditions involve the athlete being seen by the clinician at some point following the injury. Head trauma in an athletic situation requires immediate assessment for appropriate emergency action, and if at all possible, the...

InSeason Coverage

During the athlete's season, the physician's role varies considerably depending on the sport and the setting. The majority of team physicians are involved, at some point in time, in coverage of contact sports, particularly football. The majority of the following discussion centers on football with the realization that lower risk sports will generally require less frequent on-site presence of the team physician. In the majority of situations, the physicians are involved in game coverage with a...

Introduction

Hand and wrist injuries account for 3 to 9 of all athletic injuries these are being seen more frequently as recreational and competitive sports participation increases.1,2 The human wrist consists of eight carpal bones arranged in two rows, stabilized by numerous volar and dorsal ligaments that function synergistically to provide stability and pain-free range of motion. Most athletic activities involve the extremes of wrist range of motion. Therefore, physicians must identify carpal injuries...

Jeff C Brand Jr

Surgery quadriceps tendon repair Patellar tendon rupture Extensor mechanism disruptions include quadriceps and patellar tendon rupture. Bilateral atraumatic simultaneous quadriceps tendon ruptures tend to occur in patients with systemic disease. Diagnosis is made by clinical examination and radiographic findings in most instances. Surgery is necessary to restore the extensor mechanism anatomy. Rehabilitation is determined by the type and strength of the repair. Weakness, atrophy, and functional...

Jeffrey R Dugas and Amy Bullens Borrow

Ulnar collateral ligament (UCL) injury Nonoperative management Surgery UCL reconstruction Posterolateral rotatory instability Elbow arthroscopy The elbow articulation allows two major motions flexion-extension through the ulnohumeral and radiocapitellar joints and pronation-supination through the proximal radioulnar joint. The osseous configuration confers up to 50 of the stability of the joint when in full extension, but stability is increasingly reliant on soft tissues with increasing...

John E Kuhn

Scapular winging Scapulothoracic crepitus Surgery superomedial border resection Scapulothoracic bursitis Surgery endoscopic bursectomy Scapulothoracic dyskinesis Seventeen muscles have their origin or insertion on the scapula (Table 28-1 Fig. 28-1) making it the command center for coordinated upper extremity activity. A number of muscles secure the scapula to the thorax, including the rhomboideus major and minor, the levator scapulae, the serratus anterior, the trapezius, the omohyoid, and the...

Late Postoperative Rehabilitation Stage

During this phase, the drudgery of rehabilitation takes its toll. The physician must help the patient and the sports medicine therapist continue on a direct course to recovery. Continued goal orientation, provided by steadily increasing levels of activity, allows sustained patient input, and helps the patient to feel in control throughout rehabilitation. This emphasis on setting and achieving goals parallels the patient's preinjury mind set. For example, the athlete's preinjury goal may have...

Mallet Thumb

Mallet thumb injuries are much less common than the mallet finger, but this lesion may also occur as a result of athletic activity. These injuries constitute 2 to 3 of all mallet injuries, and diagnosis is usually apparent by the inability to actively extend the interphalangeal joint of the thumb. Radiographs are usually within normal limits, although occasionally a small avulsion fracture is noted. Most authors recommend78 conservative treatment of this lesion. Din and Meggitt,79 in 1983,...

Medial Gastrocnemius Strain Tennis

Medial gastrocnemius strain, or tennis leg, is a syndrome in which a sudden vigorous load causes pain and often a tearing sensation in the upper calf. Pathophysiology is an eccentric Figure 64-4 Endoscopic compartment release. The superficial peroneal nerve is seen centrally. Figure 64-4 Endoscopic compartment release. The superficial peroneal nerve is seen centrally. loading failure at the musculotendinous junction. This muscle spans both the knee and the ankle. It is so named tennis leg...

Metatarsalgia

Pain and overload of the metatarsal head region has been termed metatarsalgia. The etiology is often complex, with body habitus, foot deformity, muscular imbalance, training style, training surface, chosen sport, and shoe wear all contributing to the problem. The addition of heavy equipment to the player also increases risk of metatarsalgia. By definition, metatarsalgia is pain under the metatarsal head, and for this discussion, we concentrate on the second through fifth metatarsals. Pain under...

Mild Concussion

The mild concussion, which is the most frequently occurring (approximately 85 ), is the most difficult head injury to recognize and diagnose.15-17 The force of impact causes a transient aberration in the electrophysiology of the brain substance, creating an alteration in mental status. Although mild concussion involves no LOC, the athlete may experience impaired cognitive function, especially in remembering recent events (post-traumatic amnesia) and in assimilating and interpreting new...

Modified Brostrom Anatomic Lateral Ligament Reconstruction

In 1966, Brostrom14 first reported on 60 patients who underwent delayed direct repair of the ATFL and CFL by shortening of the torn ends and midsubstance suturing (Fig. 66-2). Gould et al35 modified this procedure in 1980 by adding an advancement of the extensor retinaculum over the Brostrom repair. The Gould modification reinforces the repair, limits inversion, and helps to correct the subtalar component of instability. Two surgical approaches are commonly used for this procedure (1) an...

Muscle Sources

We recommend that the examiner begin by asking the patient during which activities and in what position he or she is weak. As so many athletes are involved in year-round strength training, they are often very sensitive to changes in their lifting abilities and will often present early and with subtle findings. The examiner must use enough force to overcome the tested muscle. We use a standard approach to the muscular examination36 as shown in Table 16-3 (as well as the rotator cuff tests...

Natural History

It is widely agreed that when PCL injury occurs in combination with other major knee ligament injuries or when it occurs via bony avulsion, outcomes with nonoperative treatment are much poorer than with surgical intervention. The management of isolated PCL injuries is more controversial, however, because the natural history of isolated PCL injuries continues to be debated. Most series that report the results of nonoperative treatment of PCL tears include patients with mixed injury patterns and...

Neurologic Examination

Knowledge of the foot and ankle neuroanatomy is helpful in combining physical examination findings to make a diagnosis. Initial evaluation begins with testing patients for sensation to light touch. If further investigation is indicated, a 5.07 Semmes-Weinstein monofilament should be used to test sensation.6 Diabetics and others with distal neuropathies unable to feel this monofilament are thought to be below the threshold for protective sensation and at high risk of neuropathic ulceration....

Neurovascular Examination

In most athletes, the neurovascular examination will be relatively normal. However, it is still important to verify, particularly with an established diagnosis of diabetes. Figure 65-6 Testing for gastrocsoleus complex tightness (knee flexed). Figure 65-6 Testing for gastrocsoleus complex tightness (knee flexed). Figure 65-7 Testing for gastrocsoleus complex tightness (knee extended). Note relative plantarflexion of the foot indicating a tight gastrocsoleus complex.

Noninvasive Treatment

The condition is generally self-limiting with conservative means however, improvement is often gradual and commonly prolonged. Daily plantar fascia and Achilles tendon stretching are cornerstones of management25-27 (Fig. 70-16). Multifaceted con- Figure 70-16 A clinical photograph demonstrating a stretching exercise for the plantar fascia. A tennis ball is placed under the heel. Downward pressure is applied to the ball. The ball is rolled back and forth, stretching the proximal plantar fascia....

Nonoperative Management

Historically, nonsurgical management of knee dislocations was standard.25-27 Treatment typically consisted of cast immobilization for 4 to 12 weeks. Selecting duration of treatment represented a compromise between stability and motion. Knee stability generally improved while knee motion declined with longer periods of immobilization. Given the results of modern reconstruction techniques, nonoperative management should probably be reserved for those patients who are elderly or very sedentary or...

Open Repair

Earlier protocols for postoperative rehabilitation after Achilles repair advocated cast immobilization for periods of 6 to 8 weeks with the ankle in equinus. The ankle was placed in progressive dorsiflexion at 2-week intervals. After cast removal, the patient began range-of-motion exercises with a physical therapist. Some authors even advocated a long-leg cast however, Sekiya et al31 used a cadaveric study to disprove that knee position caused displacement of the Achilles tendon with the ankle...

Other Carpal Fractures

Significant forces transmitted through the wrist from a fall or collision can potentially fracture any of the eight carpal bones. Unlike the previously discussed injuries, the remaining carpal fractures are more straightforward with regards to diagnosis and treatment. Athletes presenting with significant wrist pain, swelling, or deformity require a precise physical examination with palpation of each carpal bone followed by appropriate radiographs. Subtle fractures may be difficult to identify...

Pain of Uncertain Origin

There are some pain evaluations that remain difficult even when armed with all the techniques described. Some patients simply cannot specifically describe their pain, and in others, the shoulder is so inflamed that everything seems to produce positive signs. It is in these patients that the injection tests may have their greatest utility. Before discussing these, however, there is an additional test that is reported to accurately delineate between intra- and extra-articular sources of pain....

Pain Secondary to Cervical Spine Pathology

One potentially confusing cause of pain in the shoulder is that which is referred from the cervical spine. Herniated disks can cause pressure on the C5-T1 nerve roots, which can cause vague symptoms in the anterior and posterior shoulder girdle. Patients may interpret this as shoulder pain, and thus it is incumbent on the examiner to determine exactly where the pain comes from. In such cases, the patient will not often localize the pain. The various tests that are good indicators of cervical...

Pain Secondary to Instability

As stated from the outset of this chapter, we believe that the best approach to problems with the evaluation of the shoulder is to begin with the patient's chief complaint, allowing it to immediately focus the clinical examination. It may seem odd, then, to describe a few tests for instability in a section on pain, but as pain is often the chief complaint in the athlete with instability, we remain consistent in our approach. Instability can coexist with conditions such as internal impingement...

Palpation to Reproduce Pain

Once the patient has identified the area of the pain, the next step may be to find the point of maximal tenderness by palpating each of the following areas. Keep in mind that some areas of the shoulder are naturally tender, so comparison to the asymptomatic side might be helpful (Table 16-2 Fig. 16-3). Table 16-2 Common Sites of Tenderness and Locations Pearls Greater tuberosity (Codman's point) (see Fig. 16-3) Just anterior to anterolateral corner of acromion with dorsum of hand on buttock....

Pelvis And Hip Fractures

Fractures of the pelvis and sacrum are usually pathologic due to stress or fatigue. Those fractures due to falls or high-velocity impact are uncommon and are not the focus of this section. Many stress fractures of the pelvis go undiagnosed because the prudent patient may end up self-treating with self-imposed rest until the symptoms ameliorate and activity is once again possible. When they occur, stress injuries occur at the sacrum, sacroiliac joint, pubic rami, and femoral neck. Classically, a...

Physical Examination

Skin condition and configuration of previous incisions should be inspected. Presence or absence of an effusion should be noted. Clinical varus or valgus alignment should be evaluated. Range of motion should be carefully documented and the presence and degree of flexion contracture recorded. Prone heel heights in flexion and extension can be used to assess knee flexion and extension contractures. Varus and valgus laxity should be tested at 0 and 30 degrees of flexion to evaluate collateral...

Plantar Surface

The plantar surface of the foot should likewise be specifically palpated. In the hindfoot, a painful heel pad should be differentiated from plantar fasciitis. The latter typically has tenderness at the anteromedial border of the calcaneus, whereas the former is more painful in the center of the fat pad. Warts may be distinguished from calluses by their punctuate bleeding when shaved, greater tenderness with side-to-side (versus direct) compression, and the absence of skin wrinkles passing...

Posterior Drawer Test

In this maneuver, the patient is supine with the feet on the table, the hip flexed 45 degrees and the knee flexed 80 to 90 degrees. Because the posterior drawer test is based on the relationship between the medial femoral condyle and the medial tibial plateau, comparison to the contralateral side is important in interpretation. First, the examiner must evaluate the tibial starting point. Normally, the tibial plateau step-off is approximately 1cm anterior to the femoral condyle (Fig. 53-6). If a...

Postoperative Rehabilation

Postoperative rehabilitation is conducted in phases. The first phase includes a 6-week period during which the patient is allowed passive range of motion only to allow tendon-to-bone healing to occur. During this phase, range-of-motion goals are 140 degrees of forward flexion, 40 degrees of external rotation with the arm at the side, and 60 degrees of abduction in neutral rotation. During this early phase, we do not allow the use of canes or pulleys, as these are active-assist devices. Active...

Prohormones

Prohormones such as DHEA (dehydroepiandrosterone) and androstenedione reached a peak in popularity during the 1990s as their use by high-profile athletes became common knowledge. In a survey conducted by the Department of Health and Human Services in 2002, an estimated 2 to 2.5 of high school students reported using androstenedione.81 Unfortunately, the perceived success of athletes known to use these products has been interpreted by many youths as a cause-and-effect relationship, when medical...

References

Best TM The preparticipation evaluation, an opportunity for change and consensus. Clin J Sport Med 2004 14 107-108. 2. Armsey TD, Hosey RG Medical aspects of sports Epidemiology of injuries, preparticipation physical examination, and drugs in sports. Clin Sports Med 2004 23 255-279. 3. Glover DW Maron BJ Profile of preparticipation cardiovascular screening for high school athletes. JAMA 1998 279 1817-1819. 4. Gomez JE, Lantry BR, Saathoff KN Current use of adequate preparticipation examination...

Rehabilitation For Specific Injuries

While general techniques of hand and wrist rehabilitation are sufficient in most cases, some hand and wrist injuries require specific protocols. This section details rehabilitation for several common injuries seen in the athletic population. Specific rehabilitation protocols exist for many other injuries such as tendon lacerations, tendon transfers, and ligament repairs. Readers are referred to relevant chapters in this and other texts. The spectrum of finger tip injuries includes subungual...

Relevant Anatomy

The cervical spine is composed of seven specialized vertebrae that provide a wide range of possible motions. Approximately 50 of cervical flexion-extension and rotation occurs in the upper cervical spine (occiput-C2), with the remainder distributed among the subaxial segments. Ligamentous structures provide the main support to the cervical spine as there is little inherent bony stability. This is especially true in the upper cervical spine where the transverse ligament prevents atlantoaxial...

Relevant Anatomy And Biomechanics

Hindfoot and midfoot components are easily delineated. The former is largely composed of its two bony structures, the talus and calcaneus, while the latter is composed of the navicular, the three cuneiforms, and the cuboid. Anatomically, the boundaries of the hindfoot region begin at the subtalar joint and extend to the Chopart (or transverse-tarsal) joint the midfoot begins at this joint and extends to the Lisfranc (or tarsometatarsal joint) complex. The subtalar articulation links the talus...

Results and Outcomes

In the largest series reported to date, seven of nine athletically active patients were able to return to full sport in 6 months (range, 3 to 10 months).31 Ten of 11 patients were satisfied with the result, with one patient with an acute repair dissatisfied due to sciatic nerve paresthesia. These results suggest that both early and late proximal hamstring repairs can expect to have satisfactory results, contrary to previous reports that found uniformly poor results in cases treated more than 12...

Reverse Pivot Shift

With the patient supine and the knee flexed 90 degrees, the foot is externally rotated and the knee extended with an applied Box 53-2 Classification of Posterior Cruciate Ligament Injuries16 Level 1 Posterior drawer < grade II Level 2 Posterior drawer > grade II stable to varus and Level 3 Posterior drawer > grade II unstable to varus and stress at 0 degrees or pathologic hyperextension Figure 53-7 Classification of posterior cruciate ligament injury, as assessed with the posterior drawer...

Rhabdomyolysis

Rhabdomyolysis is a disease process whereby damage sustained by the muscle fibers leads to the dissolution of the compromised structural components of the muscle fibers of the involved area. The subsequent elimination of the waste products released can be toxic to the kidneys and can lead to renal failure. Rhabdomyolysis is seen after crushing injuries and contusions but has been reported after extreme overuse episodes such as heavy or maximized weight training. It may be seen as well with...

Risk Factors For Overuse Injury

Over 25 million young athletes participate in school sponsored sports and an additional 20 million participate in extracurricular organized sports. The past decade has seen a continued increase in organized sports with more pressure to succeed, more organized and advanced leagues, more opportunities for structured play, and traveling teams. This increase in activity and participation has led to a corresponding increase in overuse injuries in this young population. Until recently, sports...

Rock Climbers Finger Injury To The Pulley

The flexor tendon sheath is a continuous structure that includes a series of thickened fibrous tunnels called pulleys. These structures function to keep the flexor tendons adjacent to the bone during flexion extension of the digit. Rupture of a pulley(s) may cause bowstringing of the tendon during flexion, which results in decreased power. The most important pulleys are the A-2, which attaches to the proximal phalanx, and the A-4, which attaches to the MP. Injury to the pulley system occurs...

Scaphoid

The unique anatomy of the scaphoid leads to a predisposition for significant functional sequelae of malunited fractures while increasing the risks for fracture nonunion and avascular necrosis. First, the scaphoid is positioned anatomically as a link between the proximal and distal carpal rows. Fracture leads to uncoupling of the distal and proximal fragments, resulting in altered load distribution and abnormal wrist kinematics. The distal fragment flexes and the proximal fragment extends...

Screening

Considerable interest has centered on the ability of the cardiovascular preparticipation examination to prevent SCD in athletes. Because of the nonstandardization of most preparticipation examinations conducted in the United States and controversy surrounding the specific elements that should be included in those examinations, an expert panel was convened by the American Heart Association in 1995 to study these issues. After thoroughly reviewing the evidence concerning cardiovascular evaluation...

Severe Concussion

It is not difficult to recognize a severe concussion, as these injuries present with signs and symptoms lasting significantly longer than mild and moderate concussions. The athlete will often experience more signs and symptoms than described in the previous two levels, and blurred vision, nausea, and tinnitus are more likely to be present. Most experts agree that a concussion resulting in prolonged LOC should be classified as a severe concussion. Some authors1,9 classify brief LOC (including...

Single Bundle versus Double Bundle Techniques

The femoral side is almost always addressed arthroscopically, although two major techniques, the single bundle and the double bundle, are possible. Early reconstructive techniques, which focused on placing a single femoral tunnel in the isometric region of the native PCL, were found to produce abnormal knee kinematics, especially when the knee flexed more than 45 degrees.20 Only 5 to 15 of the femoral footprint is truly isometric, and therefore current single-bundle methods have been modified...

Spear Tacklers Spine

Torg et al46 in 1993, after reviewing the National Football Head and Neck Injury Registry, identified a subset of athletes with an increased risk of permanent neurologic injury. These athletes had a spectrum of radiographic findings including congenital and acquired stenosis, loss of cervical lordosis, spondylosis, healed compression fractures, and instability (Fig. 15-3). In and of themselves, these abnormalities are not always associated with neurologic injury however, in combination with...

Subcutaneous Tendo Achilles Bursitis

This entity is commonly seen with retrocalcaneal bursitis, and frequently there is an element of insertional tendonitis as well. A prominence of the lateral aspect of the posterosuperior cal-caneus causes irritation of the retrocalcaneal and subcutaneous bursa as a result of poorly fitting shoes. This has been called Haglund's deformity or pump bump. The bump is usually asymptomatic until irritated by an abrasive heel counter. The prominence is classically present on the lateral side of the...

Suggested Readings

Abrams J Special shoulder problems in the throwing athlete Pathology, diagnosis, and nonoperative management. Clin Sports Med 1991 10 839-861. Burkhart SS, Morgan CD, Kibler WB The disabled throwing shoulder Spectrum of pathology. Part 1 Pathoanatomy and biomechanics. Arthroscopy 2003 19 404-420. Burkhart SS, Morgan CD, Kibler WB The disabled throwing shoulder Spectrum of pathology. Part 3 The SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy 2003 19 641-661....

Surgical Timing

Absolute surgical indications include irreducibility, vascular injury, open injury, compartment syndrome, and inability to maintain reduction with nonoperative methods. When there are no indications for emergent surgical intervention, reduction, immobilization, and MRI can be performed followed by delayed surgical intervention. Delaying surgery for 7 to 14 days will allow for appropriate vascular monitoring and reduction of swelling. This period will also allow for some capsular healing, which...

Surgical Treatment Options

If symptomatic instability persists despite an adequate functional rehabilitation program and bracing, lateral ligament reconstruction is indicated. More than 80 surgical procedures have been described to reconstruct the lateral ankle ligaments. These procedures can be grouped into either anatomic repair or non-anatomic repair. Anatomic repair is preferred as it preserves the natural biomechanics of the ankle. Nonanatomic biotenode-sis techniques are used in select cases obesity, poor soft...

Suture Passing Instruments

Several instruments have been devised to pass suture through tissue for arthroscopic shoulder surgery. We highlight a few of the devices that we use. Several other companies create devices with a similar concept. The Spectrum set is a cannulated set of curved or straight trocars used to pierce tissue and deliver suture using a manual wheeling mechanism (Fig. 17-11). It is most useful for labral repairs or capsular plications. It may also be useful in side-to-side rotator cuff repairs. Cuff...

Talar Tilt Test

Similar to the anterior drawer test, the talar tilt test is used in cases of suspected chronic ankle instability. However, it differs from the drawer test by examining primarily the CFL instead of the ATFL. Again, with the patient relaxed and the knee flexed, stabilize the leg with one hand and grasp the heel with the other. Then, with the foot first dorsiflexed (for CFL examination) and then plantarflexed (for ATFL examination), invert the hindfoot. Excessive motion may indicate instability of...

Technical Overview

The hip joint has an intra-articular and peripheral compartment. Most hip pathology is found within the intra-articular region, and distraction is necessary to achieve arthroscopic access. The patient can be placed in the supine or lateral decubitus position for performing the procedure.5,6 Both techniques are equally effective, and the choice is simply dependent on the surgeon's preference. An advantage of the supine approach is its simplicity in patient positioning while the lateral approach...