Exercise Induced Asthma

The prevalence of exercise-induced asthma ranges from 9 to 50 , depending on the sport cited.21 The acute release of bron-choconstricting agents and the chronic inflammatory airway changes, both of which are complexly intertwined, suggest two pathways to target for prevention of exercise-induced asthma attacks. A recent Cochrane review confirms that albuterol, a short-acting beta agonist, is the number one treatment for exercise-induced asthma episodes. The bronchodilating effects of albuterol...

Muscle Herniation

In the thigh and more commonly in the leg, aching symptoms may be due to muscle herniation through a defect in the encompassing fascial sheath. These defects can be congenital, spontaneous, or post-traumatic. Herniation sometimes can be grossly seen or palpated. Appreciation may be enhanced with positioning or stressing the muscle belly. MRI or ultrasonography may also be helpful in delineating areas of involvement. The most commonly encountered area of involvement is in the anterolat-eral...

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...

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.

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....

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...

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...

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

Patients with isolated chronic lateral ankle instability typically presents with complaints of periodic giving way and a history of several previous severe ankle sprains. Although these intermittent episodes are typically associated with a brief period of pain and dysfunction, most patients with isolated instability are essentially pain free between episodes and do not experience mechanical symptoms. If pain is present between episodes of giving way, secondary diagnoses must be considered...

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...

Complications

Figure 24-9 Photograph in the subacromial space showing the tied sutures of the completed percutaneous transtendon intra-articular biceps tenodesis. (From Sekiya LC, Elkousy HA, Rodosky MW Arthroscopic biceps tenodesis using the percutaneous intra-articular transtendon technique. Arthroscopy 2003 19 1137-1141.) Few complications occur in the treatment of biceps tendon disorders. Infection and neurovascular injury can occur with any surgery but are quite rare. Complications of spontaneous...

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...

Dislocation or Subluxation

Acute Conservative measures for treating acute peroneal dislocation include a below-knee cast in slight plantarflexion and inversion. Non-weight bearing in the cast is generally maintained for 6 weeks some authors advocate advancing weight bearing in the cast. After discontinuation of the cast, range-of-motion exercises are initiated. A good result after nonoperative treatment of acute peroneal dislocation occurs in 50 to 57 of patients. Eventually, 44 of patients require surgery after...

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...

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...

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...

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...

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...

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...

N

Letha Y Griffin, James Kercher, and Fred Reifsteck Shoulder instability Anterior knee pain Anterior cruciate ligament (ACL) injuries Forefoot pain Female athlete triad Anemia The past 30 years has witnessed a tremendous growth in the participation of women in sports at all levels of play (middle school, high school, collegiate, professional, and recreational levels). According to U.S. government statistics, women's sport participation increased by 700 during the 1980s. In the 2003 to 2004...

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...

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....

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...

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...

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...

Postoperative Rehabilitation

Postoperative management of biceps tenodesis is dependent on any associated procedures that were performed. In the case of a concomitant rotator cuff tear, postoperative rehabilitation is focused on protecting the rotator cuff tear. Passive range of motion is initiated, followed by active range of motion for 6 weeks before strengthening exercises are allowed. In cases in which an isolated tenodesis was performed, passive pendulum and active wrist and elbow exercises are started immediately....

Preoperative Planning

Once a diagnosis of failed reconstruction has been made, a plan should be formulated to address the identified mode of failure. Not all scenarios mandate ACL graft revision. For example, presence of an isolated cyclops lesion generating loss of motion in an otherwise stable knee without tunnel malposition can be treated effectively with arthroscopic debridement. The majority of clinical failures, however, do involve index graft revision. Although a trial of functional bracing may be considered...

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...

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

Over the past decade, rates of recurrent instability with nonoperative treatment following a traumatic anterior dislocation in several studies have been reported to be between 50 and 92 . The difference in reported recurrence rates is often correlated with the age of the patients at the time of the first dislocation. In a study of young Swedish hockey players, Cvitanic et al7 reported the recurrence rate with nonoperative treatment in players younger than the age of 20 to be greater than 90 ....

Return To Competition After Sportrelated Concussion

Over the past two decades, a number of grading scales for severity of concussion and return to play have been proposed.4,6,8-14 The lack of consensus among experts lies in the fact that few of the scales or guidelines are derived from conclusive scientific data but rather developed from anecdotal literature and clinical experience. The Cantu evidence-based grading scale (see Table 14-2) is currently recommended because it emphasizes all signs and symptoms, without placing too much weight on LOC...

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...

Scapholunate Instability

Scapholunate instability is the most common carpal instability pattern, either alone or in conjunction with another instability pattern or distal radius fracture. The most common mechanism of injury is a fall on an outstretched wrist with hyperextension, ulnar deviation, and supination of the wrist. Patients will often have pain and swelling with acute injuries. Those presenting with chronic injuries may report pain and popping with loading of the wrist. Patients may also complain of weak grip,...

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...

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....

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...

The Specialneeds Athlete

Special-needs athletes include athletes with cerebral palsy, blindness, paralysis, mental retardation, amputation, arthritis, Table 2-3 The 14-Point Musculoskeletal Screening Examination6 1. Inspection, athlete standing, facing examiner Symmetry of trunk, upper extremities 2. Forward flexion, extension, rotation, lateral flexion of neck 5. Internal and external rotation of shoulder 7. Pronation and supination of forearm 9. Inspection, athlete facing away from examiner Symmetry of truck, upper...

Thumb Ligament Injuries

The MCP joint of the thumb is a condyloid type joint.36 The osteoarticular anatomy of the thumb MP joint provides minimal intrinsic stability.37 The lateral static stabilizers include the proper collateral ligaments and accessory collateral ligaments. Dynamic stability is provided by the abductor and adductor aponeurosis. The proper and accessory collateral ligaments originate from the lateral condylar region of the metacarpal and insert on the volar aspect of the proximal phalanx and the volar...

Tibial Stress Fracture

A tibial stress fracture is another source of leg pain in the athlete. Stress fractures in general may be defined as subclinical microfractures that progress to become symptomatic and may even result in a displaced fracture when improperly treated. In the tibia, they are relatively common, representing approxi mately 17 of all stress fractures, and they are the most common stress fracture in the athlete.33 Typically, they occur posteriorly in the proximal or distal third of runners and tend to...

Transtibial versus Tibial Inlay Techniques

Two disparate methods for tibial fixation also exist. In the transtibial technique, the tibial tunnel and fixation are performed completely arthroscopically. With the patient supine, the tibial tunnel is drilled from front to back. First, any posterior adhesions are lysed and the posterior capsule separated from the tibial ridge. A PCL drill guide is passed through the inter-condylar notch and positioned slightly lateral and distal to the anatomic tibial footprint.7 The anterior portion of the...

Treatment of Soft Tissue Impingement Lesions

After a thorough diagnostic arthroscopy, anterolateral impingement lesions can be removed with the aid of the arthroscope. Bassett lesions have been found in normal ankles but can become symptomatic in the setting of inversion ankle injuries. This distal Figure 67-7 Ankle in maximal dorsiflexion without distraction. (From Van Dijk CN, Tol JL, Verheyen CC A prospective study of the prognostic factors concerning the outcome of arthroscopic surgery for anterior ankle impingement. Am J Sports Med...

Treatment Options And Recommendations

Traditionally, nonoperative treatment of isolated PCL injuries has been favored, especially with lower grade injuries. This is based on both the capacity of the ligament to heal and some outcome studies demonstrating excellent results in these patients. It appears that individuals are often able to compensate for PCL insufficiency via agonistic muscle function developed through a well-designed therapy program. Nonoperative management is currently recommended for isolated, asymptomatic PCL...

Treatment Options

The natural history of ACL deficiency is not completely understood, and comparison of operative and nonoperative management in the literature is often difficult.19 Numerous variables influence the decision-making process for nonsurgical or surgical management of these injuries. Patient age, activity level, and associated injuries all play a role in the choice of management. The activity level of the patient, as described by Daniel et al4 is probably the most predictive factor regarding the need...

1

Figure 62-11 Anteroposterior (A) and lateral (B) radiographs and sagittal computed tomography scan image (C) of a displaced fracture of the tibial tubercle. The lateral radiograph (B) shows the presence of an associated Osgood-Schlatter disease lesion. 1. Cain EL, Clancy WG Treatment algorithm for osteochondral injuries of the knee. Clin Sports Med 2001 20 321-342. 2. Fairbanks H Osteochondritis dissecans. J Bone Joint Surg Br 1933 21 67-71. 3. Wall E, Von Stein D Juvenile osteochondritis...

Volar Plate Injuries In The Thumb Metacarpophalangeal Joint

Dislocation of the thumb MP joint most commonly occurs dor-sally. The injury is secondary to a sudden hyperextension load. On-field examination of these injuries may demonstrate a mild to moderate hyperextension deformity of the proximal phalanx and dimpling within the palm (Fig. 41-18). The injuries can be classified into simple and complex. Complex dislocations are irreducible by closed methods. Radiographs demonstrating interposition of the sesamoid bones between the metacarpal head and...

Tendonitis

Tendonitis is a common wrist problem dealt with by physicians. Patients may present with pain and swelling of the involved tendons. History often reveals overuse as the inciting event, and patients report that the pain worsens with use of the inflamed tendon. Physical examination often reveals swelling and tenderness of the involved tendon. Radiographs are most often negative. de Quervain's disease involves a stenosing tenosynovitis of the first dorsal wrist compartment, which contains the...

Future Of The Preparticipation Examination

The future of the preparticipation examination is headed to the computer age. Today, there are institutions that use electronic Table 2-5 Medical Conditions and Sports Participation* Atlantoaxial instability (instability of the joint between cervical vertebrae 1 and 2) Explanation Athlete needs evaluation to assess risk of spinal cord injury during sports participation. Explanation Athlete needs evaluation. Carditis (inflammation of the heart) No Explanation Carditis may result in sudden death...

Pain Relievers Osteoarthritis Acetaminophen

Acetaminophen is a well-known pain reliever, yet it is often thought of as secondary to NSAIDs because it is thought to not possess anti-inflammatory effects (Table 5-2). However, acetaminophen has been shown to affect prostaglandin production in Table 5-2 Pain Relievers Osteoarthritis Medications Better side effect profile, especially for gastrointestinal effects No anti-inflammatory effects Less pain relief Impaired healing of muscle, tendon, and bone Decreased gastrointestinal side effects...

William M Isbell

Surgery biceps tendon repair Triceps tendon rupture Ruptures of the tendons of the elbow joint are relatively rare. Rupture of the distal biceps tendon accounts for most of these injuries. The distal biceps tendon is ruptured most commonly in the dominant extremity of patients in their 40s to 60s and is more common in men than women.1 The mechanism of injury is thought to occur from traumatic extension of a flexed elbow with a maximally contracted biceps. Degradation or degeneration of the...

Rehabilitation

Posterolateral Corner Reconstruction

There is a paucity of literature on the rehabilitation of PLC injuries, treated both nonoperatively and operatively. No con- Figure 55-9 Identification of lateral femoral position for posterolateral corner reconstruction between the lateral collateral ligament and the popliteus tendon. (From Richards RS, Moorman CT Open surgical treatment. In Fanelli GC ed The Multiple Ligament Injured Knee. New York, Springer-Verlag, 2004, pp 143-146.) Figure 55-9 Identification of lateral femoral position for...

Neurologic Sources of Weakness

Any athlete who presents with weakness about the shoulder should also be suspected of having a neurologic cause. The most common sources of this in the athlete are compression at the level of the cervical spine and neuropathy of the suprascapular A thorough understanding of the cervical spine neurologic examination is a baseline requirement for any shoulder examiner. Since cervical spine pathology can present as pain, paresthesias, or weakness about the shoulder, it is therefore a part of the...

Provocative Tests to Reproduce Pain

Subacromial Impingement-Producing Maneuvers When an athlete presents with tenderness over the greater tuberosity (especially with vague complaints involving the whole deltoid with overhead activity), one should already strongly suspect impingement. The following are provocative maneuvers that should lead one toward the diagnosis of subacromial impingement. Neer Sign This test is performed by placing the symptomatic arm in maximum passive forward flexion while stabilizing the scapula (Fig....

Practical Concepts

Organization and consistency are the key to successful shoulder arthroscopy. Certainly, the surgeon must be flexible to deal with a variety of pathologies however, certain concepts pervade arthroscopic procedures. These include arm positioning (particularly for beach chair), suture management, and shuttling techniques. Arm position plays an important role in rotator cuff and labral repairs. For rotator cuff repairs, the arm position is varied with some abduction and internal external rotation...

Nonfreezing Injuries

Immersion or trench foot is a significant cause of morbidity, particularly during military operations. Its name was first coined during World War I, after troops who stood in water-filled trenches for days developed this injury. It occurs in ambient temperatures of 0o to 10oC (32o to 50oF) and is caused by a prolonged exposure to cold water.29,32 The exact pathophysiology remains somewhat controversial, but it is widely believed that the prolonged vasoconstriction causes an ischemic injury...

Biomechanics

The understanding of the basic biomechanics of the lumbar spine begins with an understanding of the forces and stresses applied to the spine as related to the normal curvatures of the spine. Because of the lordotic shape of the spine, the results of vectorial force on the spine is usually made up of a vertical axial loading compressive force perpendicular to the surface of the disk and one horizontal to the disk, producing a shear strain. The combination of these two forces produces both...

Ligament Injuries Of The Finger Metacarpophalangeal Joint

Unlike PIP joint injuries, dislocations and ligamentous injuries of the MP joint are uncommon. The location of the joint at the base of the digits and ligamentous restraints play an important role in the stability of the MP joint. Except for the absence of the check-rein structures, the ligamentous design of the MP joint is similar to that of the PIP joint already described. It is important to note that the volar plate of the MP joint is firmly attached distally to the proximal phalanx. The...

Injection Tests

The injection of a short-acting local anesthetic provides an excellent litmus test of one's clinical examination. The presumption is that if a local anesthetic is specifically placed in an area causing pain, that pain will be temporarily and nearly completely relieved. As important, the converse is true, making injection tests sensitive and specific. Performing a successful injection test has several important principles including the accurate placement of the anesthetic, time for this to take...

Individual Sports

The lumbar spine is a highly vulnerable area for injury in a number of different sports. The reported incidence varies from 7 to 27 .4,6,19 It appears that while the incidence is significant and time lost may be significant, probably the most important problems lie in fear of spinal injuries and the necessity of a therapeutic plan. Lumbar pain is a big part of many sports, but an organized diagnostic and therapeutic plan can prevent permanent injury and allow full function and maximum...

Treatment Options Nonoperative Care

The nonoperative treatment plan begins with several basic rules. 4. Restore aerobic conditioning. To stop the inflammation of the spine in an injured athlete often requires rest and immobilization. We try to limit the rest and immobilization to the minimum. Bed rest produces stiffness and weakness, which causes the pain to persist. Stiffness and weakness are the antithesis of the body functions necessary for athletic performance. Every day of rest and immobilization may result in weeks of...

Dr Frank H Bassett III

To those of us who trained in the Duke program, the ultimate example of the team physician has always been Dr. Frank H. Bassett III. Dr. Bassett played for Coach Paul Bear Bryant at the University of Kentucky before being drafted into the military and serving in the Korean conflict. He was the first infantry soldier to try out the new body armor and this ultimately saved his life when he was shot but sustained only bruises rather than a through and through gunshot wound that would have occurred...

Chief Complaint Noise

One very common chief complaint, or at least a common concern, for athletes is popping, crunching, or grinding in the shoulder. This can run the spectrum from completely asymptomatic, inaudible noise to painful cracks that concern the patient and the examiner alike. Crepitus in the shoulder girdle should suggest an initial differential of subacromial (impingement), glenohumeral (degenerative arthritis, chondral defect, loose body), or scapulothoracic (subscapular bursitis) source. The goal of...

Shoulder

The shoulder joint sits at the center of action for most sports involving the upper extremity. Baseball pitching, tennis, gymnastics, and competitive swimming are sports that share certain similarities (Table 21-2). These overhead endeavors, while all unique, rely heavily on individual accomplishment and intensive, repetitive training. Athletes in these sports may have lengthy careers beginning at a very young age. These sports all require coordinated unrestricted shoulder motion for full...

Nba

Pudu Plate Tibial Osteotomy

Figure 58-11 Achilles tendon allograft preparation. Line drawings of the allograft with 30 x 10 x 10-mm bone block, before and after fashioning the two tails of the graft. A, Small-fragment fixation of the calcaneal bone block. Graft passage through the patellar drill holes. B, The limbs of the graft are sutured to the quadriceps tendon and medial and lateral retinaculum and then turned down for suture to the patellar tendon graft as well. (From Mills WJ Reconstruction of chronic patellar...

Epidemiology

Injuries to the fingers or hand can occur from a direct blow, a crush injury, or a laceration. A direct blow causes most pha-langeal and metacarpal fractures. This typically results in a transverse fracture. Spiral fractures occur secondary to a torsional type injury. Intra-articular fractures occur secondary to an axial load. These are the most common fracture patterns seen in the hand. Basketball players injure the PIP joint more frequently. Baseball players are more likely to sustain an...

Contributors

Hospital for Special Surgery, New York, NY Knee Graft Choices in Ligament Surgery Orthopedic Surgeon, Minnesota Sports Medicine, Minneapolis, MN. Superior Labrum Anterior to Posterior Lesions Chief, Foot and Ankle Service, Department of Orthopaedic Surgery, Carolinas Medical Center Co-Director, Foot and Ankle Fellowship OrthoCarolina, Charlotte, NC. Ankle Ligament Injury and Instability Associate Professor Director Sports Medicine Fellowship, Palmetto Health Family Practice Center, Columbia,...

Gameday Planning

Game-day planning will optimize the medical care for an athlete on the day of the event. The duties of the team physician on a game day are numerous and were covered in Chapter 1. However, essential duties of the team physician on game day to prevent, prepare for, or manage an emergency situation are shown in Box 3-1.2 TABLE 3-7 Sample Venue-Specific Emergency Protocol3 University Sports Medicine Football Emergency Protocol 1. Call 911 or other emergency number consistent with organizational...

Shoulder Instability

Internal Snapping Hip Syndrome Exercises

Shoulder laxity has been traditionally associated with the female athlete. Hormonal factors such as progesterone, estrogen, and relaxin11 as well as decreased upper extremity muscle mass12 have all been implicated. Yet there has been much debate as to whether these gender-specific differences contribute to injury patterns. The shoulder is a complex, highly mobile structure. In order to accommodate for extremes in motion, there is a delicate dynamic between normal and pathologic. The...

Creatine

Creatine is one of the most common nutritional supplements employed for possible ergogenic benefits. The Metzl et al71 survey of high school students reported use by as many as 44 of high school senior athletes, which parallels estimates of collegiate use. Creatine has become generally accepted to provide benefit in short, maximally anaerobic events, likely through enhancement of adenosine triphosphate regeneration.72 There is also some evidence suggesting a possible direct effect of creatine...

Contusion Injury

Muscle contusions represent the second most common form of muscle injury after strain injuries.35,36 This injury typically involves the anterior, posterior, and lateral thigh, as well as the anterior arm.35 In animal models of contusion, crush mechanisms result in muscle fiber rupture leading to an intramuscular hematoma, edema, and inflammation.37 Due to the hematoma formation, contusion injury is often complicated by the development of myositis ossificans. Myositis ossificans is discussed in...

Surgical Technique Biceps Tenodesis

Several techniques for tenodesis of the biceps have been described that range from all open to arthroscopically assisted to all arthroscopic. Many of these techniques require expensive implants or involve creating large drill holes in bone. Presented in this chapter is a simple all-arthroscopic percutaneous intra-articular transtendon (PITT) technique.26 This technique requires no specialized hardware and can be performed with a spinal needle, suture material, and standard arthroscopic...

Flexor Tendon Injuries

Small Finger Flexor Tendon Repair

Avulsion of the flexor digitorum profundus at its insertion on the distal phalanx is known as jersey finger. This is commonly seen in football, rugby, or flag football and usually results from grasping the pants or jersey of an opposing player. As the player pulls away, the finger is forcibly extended while the profundus continues to contract and avulsion may result. McMaster,91 in 1933, showed experimentally that a normal tendon ruptures most commonly at its insertion, less commonly at the...

History

A complete and accurate medical history is the cornerstone of a good preparticipation examination. Approximately 75 of problems can be discovered by history alone in the preparticipation examination.9 In younger athletes, emphasis is placed on fitness evaluation, obesity, maturity assessment, and identification of medical, orthopedic, and psychosocial situations.10 In older athletes, emphasis is placed on the detection of previous injuries and ongoing problems. In both age groups, one should...

Triangular Fibrocartilage Complex Injuries

One of the most common complaints about the wrist is ulnar side wrist pain. Injuries to the TFCC usually occur as the result of a hyperextension, ulnar deviation, and axially loading force and can also be found in association with distal radius fractures. However, not all disruptions of the TFCC are traumatic in nature, as inflammatory and degenerative conditions can also lead to TFCC pathology. Patients presenting with TFCC injuries may report ulnar side wrist pain, occasional clicking, loss...

Mallet Finger

Mallet Finger

Figure 41-22 Divisions of type I mallet injury showing avulsion without (A) and with (B) bone fragment. Type IV mallet injury Transepiphyseal (C) hyperflexion with fragment involving 20 to 50 of the articular surface (D) and hyperextension injury with 50 or greater articular surface, and often volar subluxation (E). (From Hastings, Rettig, Strickland Management of Extra-articular Fractures of the Phalanges and Metacarpals. Philadelphia, Elsevier, 1992.) Disruption of the terminal extensor...

V

Patellofemoral Ligament Repair Procedure

Allen Bone-patellar tendon-bone (BPTB) Hamstring tendon Quadriceps tendon Allografts Different patient characteristics dictate certain grafts. These include lifestyle (such as job and religion), sports activity, age, and pre-existing comorbidities such as previous hamstring injuries as well as patellofemoral issues such as chondrosis arthrosis, instability, previous trauma, and Osgood-Schlatter disease. In addition, surgeon comfort level with specific grafts and...

S

Fortified cereal (1 > to 3 4 cup) Growing Out of One's Sport Research studies have shown that girls play sports primarily to have fun, to exercise to get in shape, and to socialize with their peers. Boys reported that they play sports to have fun but also to gain improvement in sport skills and for the excitement of competition. When high school students were asked how they wished to be remembered, boys most frequently reported for being an athlete girls answered for being a leader in...

Mm

Figure 53-1 The origin of the posterior cruciate ligament forms an ellipse on the posterior portion of the medial femoral condyle. (From Giffin JR, Annunziata CC, Harner CD Posterior cruciate ligament injuries in the adult. In DeLee JC, Drez D Jr, Miller MD eds Orthopaedic Sports Medicine, 2nd ed. Philadelphia, WB Saunders, 2003, pp 2083-2106.) At least one ligament is present in more than 90 of specimens and both are found more commonly in younger patients, suggesting that they may degenerate...

Proximal Interphalangeal Joint Ligament Injuries

Digit Pip Dislocation Partial

Ligamentous injuries about the PIP joints are among the most common hand injuries in sports. Stability of the PIP joint is provided by the bicondylar articular anatomy, ligamentous support, extensor tendon apparatus, and the flexor tendon retinacular system.56 The key to stability is the relationship of the ulnar and radial collateral ligaments and volar plate. The lateral stabilizers of the joint include the accessory and proper RCLs and UCLs. The ligaments originate from the lateral aspect of...

Shoulder Arthroscopic Bankart Repair

Lateral Shoulder Arthroscopy Drape

Figure 18-1 A, Anteroposterior radiograph of an anterior glenohumeral dislocation. B, Normal (reduced) anteroposterior radiograph of the glenohumeral joint. C, Scapular lateral radiograph of an anterior glenohumeral dislocation. D, Normal axillary lateral radiograph. E, West Point axillary lateral with irregularity at the anteroinferior edge (arrow) consistent with a bony Bankart. Figure 18-2 A magnetic resonance arthrogram with the shoulder in an abducted and externally rotated position...

Penis Hip Capsules

Penis And Hip Arthroscopic

Be quite large.14 It is important to distinguish this from a traumatic detachment, which can also occur. Additionally, many labral tears, even in the presence of a significant history of injury, seem to occur due to some underlying predisposition or degeneration. Under these circumstances, even with reliable techniques, repair of a degenerated or morphologically vulnerable labrum would unlikely be successful. A propensity for acute articular injury has been identified among athletes associated...