Rationale For The Differentialdirected Approach

One of the early skills taught to medical students is how to perform a history and physical examination. It forms the structure and base of the clinical encounter in which a diagnosis is formulated and treatment subsequently planned. Students are taught to be organized and thorough, and although much of the necessary knowledge base will come later, the structure must be stressed early and often to have a framework in which to fill in new knowledge. Traditionally, this framework follows a fairly...

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...

Acute Medial Collateral Ligament Tear Management

For the treatment of incomplete tears, we recommend minimal immobilization for 1 to 3 weeks followed by physical therapy focusing on quadriceps- and hamstring-strengthening exercises. The senior author's management of grade III acute MCL injuries has evolved over the past 20 years. His initial recommendations were to immobilize all knees with MCL tears in a cast brace in 30 degrees of flexion for 2 weeks, which limited range of motion from 30 to 90 degrees of flexion as well as weight bearing...

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...

Athletic Pubalgia

We have recently written overviews of our current understanding of the anatomic and pathophysiologic bases for this set of syndromes.1,3 Briefly, this set of syndromes accounts for most of the surgical problems that we see in athletes. Athletes create tremendous torque that occurs at the level of the pelvis. The anterior pelvis takes much of the brunt of these forces. The attachments to the anterior pelvis play the most important roles with respect to the direct and opposing forces that are...

Betahydroxybetamethylbutyrate

Beta-hydroxy-beta-methylbutyrate (HMB) is a relatively new product marketed as an anti-catabolic compound. Use of HMB has been associated with increased lean muscle mass and decreased CPK levels after exercise, but the mechanism of these effects is unclear.72 In a separate study, brief use of HMB did not prevent common effects of exercise such as muscle soreness or swelling.88 Other studies have shown HMB does not have an androgenic effect nor does it have a significant impact beyond resistance...

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...

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 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...

Chronically Anterior Cruciate Ligament Deficient Knee

When addressing concomitant injury to articular cartilage in the context of the chronically ACL deficient knee, several very important points must be weighed (1) the extent of damage to articular cartilage, (2) the status of the menisci, and (3) evidence of angular malalignment. Accurate determination of extent of articular involvement in the painful, unstable knee is perhaps of paramount importance. Significant involvement of two or more compartments may preclude attempts at joint salvage....

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 evaluation of a patient with hip pain focuses on whether the source of symptoms is intra-articular and thus potentially amenable to arthroscopy.2 Characteristic features of hip joint pathology are summarized in Table 45-1. In general, a history of a specific traumatic event is a better prognostic indicator than a patient who simply develops insidious onset of hip pain. Onset of symptoms in the absence of injury implies a degenerative process or predisposition to damage that is less likely...

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...

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...

Epidemiology

STANDARD NEUROLOGICAL CLASSIFICATION OF SPINAL CORD INJURY Finger flexors (distal phalanx of middle finger) CS against gravity 4 active movement, _1 Voluntary anal contraction (Yes No) S4-S Figure 15-1 American Spinal Cord Injury Association classification of spinal cord injury. PIN PRICK SCORE (max 112) LIGHT TOUCH SCORE (max 112) Figure 15-1 American Spinal Cord Injury Association classification of spinal cord injury. PIN PRICK SCORE (max 112) LIGHT TOUCH SCORE (max 112) NEUROLOGICAL R L ZONE...

F

History and physical examination Imaging Surgery hip arthroscopy Loose bodies Labral tears Articular cartilage injury Ligamentum teres injury Synovial disease Impinging osteophytes Instability The indications for hip arthroscopy fall into two broad categories. In one, arthroscopy offers an alternative to traditional open techniques previously employed for recognized forms of hip pathology such as loose bodies or impinging osteophytes. In the other, arthroscopy offers a method of treatment for...

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...

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....

Heat Illness

Every summer the topic of heat illness gains increased press in the news headlines. Much of this press is related to the fact that heatstroke is the third most common cause of exercise-related death in U.S. high schools, following head injuries and cardiac disorders.1 With the increasing popularity of endurance and ultraendurance competitions (marathons, ultra-marathons, and triathlons), our understanding of exercise-associated collapse (EAC) falls into question. No longer can an athlete who...

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...

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...

Metatarsalgia

Turf Toe Syndrome

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...

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....

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...

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....

Partial Or Complete Meniscectomy

When nonoperative care is unable to provide pain-free function or the knee demonstrates locking, surgical intervention is nearly always performed using arthroscopic techniques. Following these procedures, patients should be urged to regain quadriceps control as quickly as possible. A useful treatment pearl is to initiate quadriceps contraction with the knee flexed at least 30 degrees to increase capsular volume (open pack joint position), also placing the muscle on a slight stretch to...

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...

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....

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 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 ....

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...

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...

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....

Surgery

Prior to surgical reconstruction of the ACL, a thorough examination under anesthesia should be performed by the operating surgeon. Depending on the certainty of the diagnosis and surgeon preference, one may either proceed directly to graft harvest or diagnostic arthroscopy. In the case of allograft reconstruction, graft preparation may be performed prior to the initiation of surgery (Fig. 51-9). An 8 cm long incision is made just medial to the midline centered over the patellar tendon and...

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 Decision And Implementation

Choosing treatment options is easier if the first two stages are managed satisfactorily, that is, if the patient has accepted the reality of the injury and is psychologically prepared to assume an analytical role in helping to choose the appropriate treatment. Treatment may be easily decided on in some cases, but when many issues are involved, the decision can be difficult to make. For instance, treatments may affect a patient's career or a team's performance and the physician should be aware...

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

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...

Turf Toe Injuries

Originally described as occurring on artificial turf surfaces, turf toe injuries involve a primarily hyperdorsiflexion force to the first metatarsal phalangeal joint.14 Varus and valgus forces may also play a role and may increase the likelihood of late instability. These injuries occur in football, soccer, dance, and other sports that involve great toe dorsiflexion activity. The injury involves primarily the plantar plate the sesamoid complex and the collateral ligaments are injured depending...

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...

Tendonitis

Tendon Gliding For Quervain

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...

Functional Range of Motion

Normal values for joint range of motion can be found in Table 65-1. Start by evaluating the heel cord and gastrocsoleus complex (GSC) for excessive tightness. Passively dorsiflex the foot while the knee is flexed and note the motion. Then pas Figure 65-7 Testing for gastrocsoleus complex tightness (knee extended). Note relative plantarflexion of the foot indicating a tight gastrocsoleus complex. sively extend the knee while holding the foot dorsiflexed. Because the GSC crosses the knee and...

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...

N

Mininder Kocher, Rachael Tucker, and Patrick Siparsky Psychosocial aspects of sports participation Nutrition Performance enhancing substances Arthroscopy Epidemiology of Pediatric Sports Participation Over the past 30 years, there has been a significant increase in the number of children and adolescents participating in physical activity and team sports, with the largest increase among adolescent females.1 The overall trend has seen a shift from the largely unstructured, unsupervised free play...

Ligament Injuries Of The Finger Metacarpophalangeal Joint

Brewerton View Hand Ray

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...

Relevant Anatomy

Walch et al6 first described internal impingement as intra-articular contact between the posterosuperior rotator cuff (infraspinatus) and posterior glenoid labrum at maximal shoulder abduction and external rotation in tennis players. Anatomic lesions associated with internal impingement include injury to the articular surface of the rotator cuff (especially the infra-spinatus tendon in throwers and the supraspinatus tendon in tennis players), posterior and superior labrum, and anterior capsular...

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

Tibial Tubercle Osteotomy Scar

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...

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,...

Shoulder Instability

Breast Tumor Jpg

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

Pcl Double Bundle

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

Medial Collateral Lig Laxity

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

Arhtroscopic Shoulder Plication

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...

Hook Of The Hamate

The hamulus, or hook of the hamate, protrudes into the palm surrounded by critical soft-tissue structures. The hook serves as the origin of the flexor and opponens digiti minimi muscles and forms the ulnar border of the carpal tunnel and radial border of Guyon's canal.1 The deep motor branch of the ulnar nerve courses around the base of the hook with the superficial sensory branch remaining in close contact with the tip. The hook also functions as a pulley for the superficial and deep flexor...

Patellofemoral patients

Assessment determines the primary factor. 1. Ligamentous instability (ligament incompetency laxity) 2. Tension (inability to tolerate high loads, especially eccentric loads) 3. Friction (inability to tolerate repeated flexion extension activities) 4. Compression (inability to tolerate compression loads, weight-bearing activities) Figure 63-3 Patellofemoral patients. Table 63-1 Ligamentous Instability Rehabilitation Pearls* Avoid terminal extension (patella must not laterally bias excessively)...

Metacarpal Fractures

Closed Reduction Percutaneous Pinning

Metacarpal neck fractures account for as many as 36 of all fractures of the hand.8 Metacarpals are weakest at the metacarpal neck and are often fractured by a direct blow, torsion, or bending load applied to the digit distally. Most metacarpal neck fractures affect the ring and little fingers. The most famous of these is the Boxer's fracture (although rarely seen in boxers), a fracture of the fifth metacarpal neck. Fractures at this level occur secondary to the instability of the ulnar digits...

Modified Brostrom Split Evans Procedure

Evans Procedure

In 1953, Evans36 described a biotenodesis procedure in which the peroneus brevis tendon is released at the musculotendinous junction, rerouted through the fibula, and then reattached to its proximal stump. This procedure was later modified by suturing the tendon back to itself instead of reattaching it to the proximal stump.37 In 1999, Girard et al38 reported on their results of the modified Brostrom-Evans procedure, a procedure that augments the Brostrom reconstruction with the addition of the...

Bilateral Stance On Unstable Surface

Single Leg Stance Foam

Witvrouw et al42 prospectively studied the risk factors for the development of anterior knee pain in the athletic population over a 2-year period. A significant difference was noted in the flexibility of the quadriceps and gastrocnemius muscles between the group of subjects who developed patellofemoral pain and the control group, suggesting that athletes exhibiting tightness of specific muscles may be at risk of the development of patellofemoral disorders. In the upper extremity, it is common...

Surgery Hip Arthroscopy

Maquet Extension

The technique illustrated is with the patient in the supine position. The important principles for performing safe, effective, reproducible arthroscopy are the same whether the patient is in the lateral decubitus or supine orientation. Portal placements, relationship of the extra-articular structures, and arthroscopic anatomy are all the same regardless of positioning. A standard fracture table or custom distraction device is needed to achieve effective joint space separation. A tensiometer can...