References

Burkhart SS, Nottage WM, Ogilvie-Harris DJ, et al Partial repair of irreparable rotator cuff tears. Arthroscopy 1994 10 363-370. 2. Burkhart SS Arthroscopic debridement and decompression for selected rotator cuff tears. Clinical results, pathomechanics, and patient selection based on biomechanical parameters. Orthop Clin North Am 1993 24 111-123. 3. Burkhart SS Partial repair of massive rotator cuff tears The evolution of a concept. Orthop Clin North Am 1997 28 125-132. 4. Magarey ME, Jones MA...

Hypertension

Hypertension remains one of the most prevalent medical conditions treated in primary care and has been cited as the most common medical indication for disqualification or mandatory follow-up in athletic medicine.1 Although multiple classes of medications have been introduced over the years to treat hypertension, the most recent expert guidelines on management of hypertension continue to support primary treatment with diuretics, with possible early addition of a b-blocker or...

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...

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...

Athletes with a Helmet and Face Mask

Particular attention needs to be given to emergency conditions occurring in the athlete wearing a helmet and face mask. Unless there are special circumstances such as respiratory distress coupled with an inability to access the airway, the helmet should never be removed during the prehospital care of the athlete with a potential head or neck injury.1 The helmet and shoulder pads hold the cervical spine in relative alignment, and removal of them would cause movement of the cervical spine that...

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...

Dti

Figure 51-11 A, Incision site for harvest of autogenous hamstring graft. B, Isolation of gracilis and semitendinosis tendons. A closed tendon stripper is then used to complete the individual tendon harvest. harvest. A provisional pin is advanced into the ACL footprint using the guide. The aiming guide is then removed and the pin is overreamed with a cannulated reamer of appropriate size (Fig. 51-13A). Any remaining bone fragments are then removed with the use of a motorized shaver. The femoral...

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...

Cervical Disk Herniations

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

Cervical Stenosis

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

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

Classification of orthopedic injuries can be useful for both effective communication between physicians and development of appropriate treatment strategies. Multiligament-injured knees can be classified based on the following parameters (1) joint position, (2) injured structures, (3) energy level, and (4) chronicity. Classification of knee dislocations is summarized in Table 56-1. Historically, knee dislocations like other joint dislocations, have been classified based on the position of the...

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...

Diagnostic Arthroscopy of the Ankle

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

Dislocation or Subluxation

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

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...

Game Coverage

The team physician needs to be present on the game day for contact sports such as football. There are several different logistical arrangements, depending on the level (Box 1-2). At our institution, the team physician arrives 90 minutes prior to the posted kick-off time. Final evaluations are made at this time and any concerns addressed. Under some circumstances, it may be appropriate for athletes with soft-tissue injuries to receive intramuscular ketorolac (Toradol) injections 1 hour prior to...

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....

Head And Spinal Cord Injury

One of the more common emergency conditions encountered during coverage of athletic events are head and neck injuries. Any athlete that has altered mental status, neck pain, or neurologic complaints should be considered to have a spinal cord or brain injury. By properly managing head and neck injuries, the medical team can lessen the chance of complications and expedite emergency transportation. The first step in managing a cervical spinal injury is cervical immobilization. This immobilization...

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...

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...

Imaging Of The Cervical Spine

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

Implants

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

Initial Onsite Assessment

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

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...

John E Kuhn

Carotid Artery Endarterectomy

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...

Major Fractures

Major fractures and fracture dislocations do occur in sports. Although discussion of these injuries is beyond the scope of this text, most major fractures are the result of flexion and axial loading. Rotational forces also may cause major fracture dislocations. These fractures include compression and burst fractures, facet fractures, and dislocations as well as extension-type injuries. The majority of these injuries ultimately require surgical intervention for decompression of the spinal cord...

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...

Minor Fractures

Compression fractures, spinous process fractures (clay-shoveler's), and lamina fractures can occur during athletic participation. Hyperflexion can lead to both compression or spinous process fractures, and axial loading is associated with lamina fracture.48,49 Cervical immobilization should be maintained throughout the evaluation. Plain radiographs and computed tomography scanning should be performed and scrutinized for evidence of instability or associated ligamentous injuries. Nondisplaced...

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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...

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 Secondary to Cervical Spine Pathology

Spurling Test

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...

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...

Positioning

Positioning the patient may seem trivial, but if done inappropriately, it may aggravate cervical spine, lumbar spine, or other patient pathology. In addition, poor positioning adds to the difficulty of the procedure. Patients may be positioned in either the lateral decubitus or beach chair position. Other positions have been described including hybrids of the beach chair and lateral decubitus posi-tions.1 We perform all shoulder arthroscopy in the beach chair position. A Schloein positioner...

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....

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...

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...

Scaphoid

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

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,...

Scoliosis

Knowledge of common spinal deformities and the effects strenuous sporting activities have on the developing spine is especially pertinent to diagnosis, outcomes, and level of participation in the female. Scoliosis is defined as the lateral and rotational curvature of the spine. Idiopathic scoliosis refers to the presence of curvature in the absence of congenital or neurologic abnormalities. Idiopathic scoliosis is the most prevalent form of scoliosis, accounting for approximately 70 of all...

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...

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....

Summary

Cervical spine injuries are relatively common in athletes today. Fortunately, the vast majority are minor without long-term morbidity. It is critical to understand the pathoanatomy of cervical spine injuries and their implications for treatment. There is no universal agreement on return to play criteria. The decision to Figure 15-7 Lateral cervical spine radiograph demonstrating bilateral facet dislocation. Note greater than 50 anterolisthesis of the C5 vertebral body on the C6 vertebral body....

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...

Techniques

The posterior approach to the shoulder begins with a vertical incision extending from approximately 1 cm medial to the pos-terolateral corner of the acromion and extends down toward the posterior axillary fold. Dissection is carried down to the deltoid muscle, which is split in line with its fibers from the scapular spine extending inferiorly. Classically, the approach is then continued in the internervous plane between the infraspinatus and teres minor, dividing this interval transversely to...

The Specialneeds Athlete

Strapse Lackkleid

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

Tibial Dreaded Black Line

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

Visual Fissure Caries

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 Operative Care

The chief indications for spine surgery in the athlete are the same indications for spine surgery in any patient 1. Sufficient morbidity to warrant surgery. 2. Failure of conservative care. 3. An anatomic lesion that can be corrected with a safe, effective operation. 4. A proper, fully developed postoperative rehabilitation program. A proper postoperative rehabilitation program cannot be overemphasized. The failure to do postoperative spinal rehabilitation would be similar to a failure to do...

Treatment Options

Examen Otoscopique Normal

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...

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

Suture Hooks

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...

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...

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...

Ryan Nunley Md Orthopedics Mail

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

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...