Chrisman Snook Reconstruction

The Elmslie39 procedure is a nonanatomic reconstruction of the lateral ligaments that uses a strip of fascia lata passed through drill holes in the distal fibula and calcaneus. Chrisman and Snook40 modified the Elmslie procedure using a split portion of the peroneus brevis and published their results in 1969. The course of the peroneus brevis graft is designed to recreate the vectors of both ATFL and CFL. The surgical technique for the Chrisman-Snook reconstruction is performed through a...

Treatment Options

Nonoperative treatment of rotator cuff disorders provides the possibility of avoiding the inherent risks of surgery. Failure of nonoperative treatment results in continued or recurrent symptoms and or progression of pathology, leading to eventual surgical treatment, possibly after irreversible changes have occurred in the rotator cuff. When counseling patients regarding treatment options, it is helpful to characterize a cuff disorder with respect to the patient's age, the tear size, injury...

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...

Relevant Anatomy And Biomechanics

Accurate diagnosis and effective treatment of rotator cuff disease relies on an appreciation of shoulder anatomy and bio mechanics. Structures that contribute to normal function will also influence pathologic conditions of the rotator cuff. An awareness of the discerning features of a patient's history and physical examination, and an understanding of potential contributions from surrounding structures will assist in developing a differential diagnosis and formulating an effective treatment...

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

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...

References

Andrews JR, Dugas JR Diagnosis and treatment of shoulder injuries in the throwing athlete The role of thermal-assisted capsular shrinkage. AAOS Instr Course Lect 2001 50 17-21. 2. Halbrecht JL, Tirman P, Atkin D Internal impingement of the shoulder Comparison of findings between the throwing and nonthrowing shoulders of college baseball players. Arthroscopy 1999 15 253-258. 3. Jazrawi LM, McCluskey GM III, Andrews JR Superior labral anterior and posterior lesion and internal impingement in the...

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...

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

Transverse Pullbacks

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

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

Periosteal Sleeve Shoulder

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

Anterior Penis Point

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

Midshaft Metacarpal

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

Rhythmic Stabilization Sidelying

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

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...

Pearls And Pitfalls In Release Lateral Arthroscopy Patellar

Fluid Knee After Acl Surgery

A high-flow pump is especially helpful, maintaining a high flow rate without excessive pressure, which would worsen extravasation. Hypotensive anesthesia, placing epinephrine in the arthroscopic fluid, and electrocautery or other thermal device for hemostasis all aid in visualization for effectively performing the excision. Hip instability can occur but is much less common than seen in the shoulder. There are several reasons, but, most principally, it is due to the inherent stability...

R Shane Barton David Mayman Peter J Millett and Thomas J Gill

Scapulothoracic Instability Treatment

Peripheral nerve injury Burner stinger syndrome Suprascapular nerve entrapment Surgery suprascapular nerve decompression Axillary nerve injury Long thoracic nerve injury Spinal accessory nerve injury Musculocutaneous nerve injury The pathophysiology of peripheral nerve injury has been studied in great detail. Seddon1 developed the classification system most commonly used today, defining three progressive patterns of injury severity. This has been further modified by Sunderland2 to include five...

Rotational And Torsional Sports

Rotational and torsional sports have certain characteristics in common. Baseball, golf, and the javelin all require rotation and have distinctly different demands on the spine. The javelin requires a tremendous amount of force to be generated in going from a hyperextended to a full flexion follow-through position. You do not throw a javelin 200 feet with your arm. While shoulder and arm injuries are common in javelin throwers, the key is rigid abdominal strength that produces the torque...

Laurence Laudicina and Thomas Noonan

Arcade Frohse

Lateral tendonosis (tennis elbow) Medial tendonosis (golfer's elbow) Olecranon bursitis Olecranon stress fracture Valgus extension overload Nerve compression syndromes LATERAL TENDONOSIS EPICONDYLITIS (TENNIS ELBOW) Lateral epicondylitis or tendonosis is usually an overuse injury, although it may be precipitated by minor elbow trauma. The condition is typically due to repetitive flexion extension or pronation supination with the elbow near extension. It generally presents as lateral-side elbow...

Surgical Technique

The patient is placed supine on the operating room table, with both the injured and uninjured legs in the extended position. A lateral valgus bar is placed next to the injured thigh. A thorough examination under anesthesia is carried out prior to proceeding with the definitive procedure. A bump of towels is placed under the injured knee. We have found arthroscopic evaluation of the knee with both acute and chronic posterolateral rotatory instability as a valuable adjunct to the open procedure....

Methamphetamine

Methamphetamine may have replaced cocaine in popularity as an illegal stimulant and euphoric. Methamphetamine is the number one controlled substance produced clandestinely since 1997. Methamphetamine should be considered ergogenic in the same manner as the class of amphetamines and other stimulants, with delayed time to exhaustion and improved ratings of perceived exertion. Its short-term effects include decreased appetite and increased energy, along with increases in heart rate and body...

Sesamoid Problems

Bipartite Medial Sesamoid

In the vast majority of the population, there are two small sesamoid bones under the first metatarsal head. They are incorporated into the medial and lateral heads of the flexor hallucis brevis tendons and are termed the tibial and fibular sesamoids. Sesamoid problems are more common in women, possibly due to the greater degree of dorsiflexion present normally in their first metatarsophalangeal joints and more common in the tibial sesamoid. Up to 50 of body weight may be carried by the first...

High Altitude Illness

High altitude has captivated athletes and adventure seekers for years. Athletes subject themselves to living high and training low in the hopes of achieving that small edge to push them past their competitors. Extreme athletes traverse harsh and dangerous terrain, pushing the limits of human physiology in search of excitement and adventure. In recent years, the adventure travel industry has boomed by providing quick and rapid excursions for individuals who may not be prepared emotionally or...

History of Present Illness and Injury

After the chief complaint, the next step of the history should be the history of the present illness. The purpose of the history of the present illness is to reconstruct the story of the chief complaint (from onset to present) so that the examiner has a clear understanding of how things started, what has been previously done, and the current state of the problem. The athlete may be unclear as to how or why symptoms started and may describe an insidious onset. When a single traumatic event is...

Principles Of The Physical Examination

Once the examiner completes an organized history, there should be a clear idea of the differential, and this should direct which aspects of the physical examination should be emphasized. Just as in the history, there are certain expected responses (both positive and negative) for the differential-directed physical examination. During the examination, one should note whether the physical examination expectations are met (in which case the suspicion of the correct diagnosis is strengthened) or...

Tests for Weakness Jobes Test

Full Can Test

This test is performed by placing the patient in 90 degrees of elevation in the scapular plane, classically with the thumbs pointed down (Fig. 16-7). This position is held against downward resistance. This test isolates the supraspinatus to a degree10 and is positive when there is asymmetrical weakness. Caution should be used in the patient with pain, as it can simulate weakness in patients with painful subacromial impingement. Because Jobe's test can be painful in patients with impingement,...

In This Chapter

Medial patellofemoral ligament (MPFL) reconstruction Finally, the role of proximal and distal realignment for treatment of patients with patellofemoral malalignment and or instability is explored. The decision-making process in assessing malalignment instability of the patellofemoral articulation, the criteria for tibial tubercle transfer in both the medial and anteromedial direction versus proximal realignment, and details of the surgical techniques are addressed. Patellofemoral instability...

Osteitis Pubis

Osteitis Pubis Causes

Osteitis pubis in the athlete is an inflammatory condition of the pubic symphysis and surrounding structures. Due to the ubiquitous nature of this disease, it is imperative that all factors, such as infection, urologic, gynecologic, and rheumatologic issues are taken into consideration for the accurate diagnosis and treatment. The pathogenesis of this disorder remains obscure. It can occur secondary to vertical instability or as a primary condition. It may also coexist with other conditions...

Conclusions

The lines between treating illness, maximizing health, and sports performance enhancement have been blurred by well-intentioned medical advances and societal pressures that lead athletes of all levels to seek a competitive edge. Unfortunately, for many athletes the inappropriate use of medications, supplements, and other drugs not only damage the image of their sport but also cause significant health consequences that extend well beyond the field of competition. Sports medicine professionals...

Alo

Loss Flexion Penis

Shelbourne et al20 developed a classification system of arthrofibrosis based on the motion of the injured knee compared to motion in the uninjured knee. In this classification system, patients with type I arthrofibrosis have an extension loss of 10 degrees or less and normal flexion. Patients with type II arthrofi-brosis have greater than 10 degrees of extension loss and normal flexion. Patients with type III arthrofibrosis have greater than 10 degrees of extension loss, greater than 25 degrees...