Sports Medicine Miller Review

Sports Medicine Knee Anatomy o Simultaneous rotation and translation o Articular cartilage  Type II collagen  Mostly water  Increased water and decreased proteoglycans w/ DJD  When torn, heals with type I collagen (fibrocartilage) o ACL  33mm x 11mm  2 bundles  AM tight in flexion  PL tight in extension  Supplied by middle geniculate artery o PCL  Wider than ACL  2 bundles  AL tight in flexion  PM tight in extension o Meniscofemoral ligaments  Humphrey anterior  Wrisberg posterior o MCL  Attaches to meniscus (deep portion) o LCL  Tight in extension  Capsule most distal extent is posterior to fibula o Strength  MCL > PCL > ACL > LCL o PL corner  Superficial: biceps, ITB  Deep: LCL, popliteus, popliteofibular lig, posterolateral capsule o PF joint  Patella increases moment arm of quadriceps  Fully engaged @ 40 deg  Forces = 3-5 x body weight  Medial patellofemoral ligament  Acts as checkrein  Primary restraint to dislocation o Meniscus  Medial - semicircular  Broad attachments to horn  Firm attachments  Wider post than ant Lateral – circular/C-shaped  Attachments close to ACL  Loosely attached  Post/ant = in width  Posterior horn of MM 2nd stabilizer to anterior translation  Meniscus is type I collagen  Transmit 90% of load w/ knee in flexion  transmit 50% of load w/ knee in extension  Lateral meniscus 2x excursion of medial o Transm greater % of load compared to MM ER asymmetry (Dial test)  If dial at just 30, then PLC injury  If dial at 30 and 90, then PLC and PCL injury Patella baja – associated w/ arthrofibrosis OCD – lateral aspect Medial femoral condyle Stress radiographs  For PCL measurement  If > 12 mm, then probably PCL and PLC injury ACL  Bone bruise  Lateral femoral condyle (mid 1/3)  Lateral tibial plateau (post 1/3) Posterior horn MM tear  AL and PM portals for best visualization - Quad rupture > 40 - Patella rupture < 40  o o o o o o Meniscal tears - Higher risk in ACL-deficient knee - Medial > lateral - ACL injury – lateral meniscus more common o Small lat tears can be tx nonsurg - MRI false positives for o Anterior horn MM o Intraseptal degeneration – called tears - Repair peripheral vertical tears 1-4 cm in length o Most peripheral 25% of MM and 15% of LM have consistent vasc supply o Branches from sup, inf, lat geniculate A supply this zone Sports Medicine o Area in PL aspect of lat meniscus by popliteus is watershed area hypovascular Improved meniscal healing w/ combined ACL reconstruction Inside-out technique strongest (vertical mattress suture) Longtitudinal tears heal better than complex tears Acute tears (< 8 wks) have better results than chronic Degen changes on XX and dec in fx shown earlier in pt w/ lateral menisc than those w/ medial menisc Meniscal repair risks o Medial: saphenous N/V, popliteal vessels o Lateral: peroneal N, popliteal vessels  Place retractor deep to head of gastroc Strongest repair o Vertical mattress suture Meniscus transplantation o Avoid grade IV chondrosis – indications controversial o Mechanical alignment should be nl o grafts w/o bony base have higher fail rate Meniscal cysts o Associated w/ LM horizontal tears – to periphery o Tx: arthroscopic decompression, partial meniscecetmy Discoid meniscus o Type I incomplete o Type II complete o Type III Wrisberg (no coronary attachments) – free  Tx w/ meniscus repair o If discoid no tear – then leave it alone o Dx: MRI w/ 3 consecutive images w/ sagittal continuity o Wedge-shaped o Core decompression SONK o Subchondral insufficiency fracture o Can follow arthroscopy in older pt  Several month recovery Arthroscopic synovectemy as good as open synovectemy o Just need multiple portals Medial plicae most common - - - - - - - - OCD in knee - Only operate on adults or kids who are symptomatic - Articular cartilage defects - Atraumatic ON o Related to steroids ACL injuries - Cannot primary repair o Covered by myofibroblast-like cells w/ alpha-smooth muscle actin - Operative tx reduces incidence of chondral and meniscal injury - Injuries while jumping have inc in intra-art inj - Females w/ fourfold inc risk of ACL tears - Graft choices o PT: anterior knee pain  Contralateral pat tendon lead to dec morb on reconst knee, faster pt recovery o Hamstring: fixation failure  Highest strength and stiffness o Quad o Allograft  HIV risk 1:1 million  Slow chronic immunol resp to tissue o Preconditioning of grafts can reduce stress relaxation by 50% o Irradiation of > 3 mrads required to kill HIV (but affects structural properties) o Late arthritis related to meniscal integrity - Postop rehab o ROM - extension first  Especially w/ medial sided surgery (patellar dislocation, MCL repair) o Avoid isokinetic quad strengthening 15-30 deg during early rehab o Immediate weightbearing reduces PF pain - Reconstruction complications o Tunnel placement Sports Medicine Femoral 1-3 mm w/in over-top position  Tibial should be posteromedial aspect of ACL footprint  Posterior to Blumensaat‟s Line o Arthrofibrosis o Hdwr failure (early cause of failure – 1st 6 wks) o Missed concurrent injuries o Most patellar fractures occur 8-12 wks postop  Reduced w/ smaller blade, triangular graft, bone grafting lesion, drilling holes at corners, less rectangular graft  Cyclops lesion  Dx w/ „click‟ at terminal extension  Fibroproliferative tissue blocks extension Loss of motion prevented w/ o Full ROM preop o Correct tunnel placement  If femoral tunnel anterior (in front of blumensaat‟s line) – strain in flexion  Tunnel too posterior – strain in extension  “over-the-top” position  Tibial tunnel angle of 75 deg or more in coronal plane ass w/ greater loss of flexion and anterior laxity Sport-specific validated measures of outcome o Knee Injury and OA Score o IKDC questionnaire Outcomes o 44% w/ PBTB had 3 deg loss of ROM o 43% w/ hamst had hamst weakness o 43% using pat tend more stable by KT1000 than hamst (1-3 mm) o 89% no diff in ant/PF pain o pat tend w/ more kneeling pain Prevention of ACL injury o Skier training o Female athlete – NM training, plyometrics beneficial (land in less extension)  o ACL bracing only effective in skiers Midsubstance ACL tears in young children o Femoral tunnel causes growth problems o Soft tissue graft for young o Use a vertical tunnel - PCL injury - MOI: blow to tibia - Hyperflexion - If bony avulsion off tibia, o Then ORIF - Isolated PCL o Nonoperative o Quad rehabs o Extension brace for 2-4 wks for grade III injuries o Late chondrosis in MFC and patella o If post drawer improves w/ internal rotation, then nonoperative (PLC tight) - Postop o Immobilize in extension, quad rehab - Inlay technique results in less graft attrition and failure o Posteromedial approach b/w semimembranosus and medial gastroc - 2-bundle technique results in better stability in extension and flexion - increased OA in medial and PF compartments in cadaver studies without PCL MCL injury - MOI: valgus contact - Open only at 30 deg - Tx: hinged knee brace 6-8 wks - Delay ACL reconstruction in combined ACL/MCL injuries LCL injury rare - Tx: isolated – brace - Combined – repair/reconstruction PL corner - Includes biceps tendon, IT band, popliteus, PF lig, arcuate lig, LCL o Biceps femoris is dyn lat stab of knee o IT band is anterolat stab of knee o Popliteus ER femur - - - Sports Medicine o PF lig prev resist to post transl, ER of tibia  Controls PL rotation of tib on femur o LCL prim static restraint to varus stress, second restraint to ER of tibia Combined PCL > ACL If missed, may be late cause of failure of ACL/PCL reconstruction Grade I and II instab tx w/ 3-wk period of immob w/ knee in ext PE: o ER asymmetry o ER recurvatum o PL drawer o Tx: acute w/ supplementation (free graft)  Reconst recreating popliteus tenson and LCL fare best  Reconstruct chronic – popliteofibular ligament ITB syndrome - Hill runners - PE: Ober Test o Abduct, extend position – then adduct the leg - Tx: stretching Recurrent patellar instability - XX: patella alta, sulcus sign - RF: patella alta, lig laxity, lat fem condyle hypoplasia, lat insertion of pat tendon, inc Q angle - Fulkerson o Contraindicated in pt w/ superomedial patellar arthritis (will concentrate stresses in that area more) Knee Plica - three synovial plica described: suprapatellar, medial shelf, infrapatellar Lateral patellar compression - Tight lateral retinaculum - inc Q angle - Only indication for surgery release – tilt on XX, refractory rehab o 60-90% successful results Patellar chondrosis - Tubercle elevation – can elevate 1 cm PF syndrome - Tx: rehab o Closed chain short arc quad exercises, 0-30 extension - PF contact pressures lowest b/w 0-30 knee flexion Extensor Mech Disruption - delay in surg repair is factor most sign diminishes results b/c contracture of tissue Bipartite patella - Male > female - Superolateral portion of patella Athletic Pubalgia - Knee Dislocation - inj to popliteal A more likely w/ post disloc o inj by stretching second to tether of vessesl at add hiatus or o direct contusion by post tib plat - inj to common peroneal N. more likely w/ PL disloc o estim 20-30% disloc - Delay surgery to o Allow vasc monitoring o Reduce risk of arthrofibrosis Proximal tib-fib dislocation - MOI fall on flexed knee - Anterolateral common - Closed reduction – flexion and pressure - Postop – immobilize in extension - Tx: chronic – prox fib resection Bioabsorbable materials - Polyglycolic acid – absorbs in weeks - Polydioxadone – absorb in months - PLLA – absorbs in knees Prepatellar bursitis - In wrestlers – then aspirate Sports Medicine Lower abdominal, inguinal pain at extremes of exertion o Abd hyperextension o Thigh hyperabduction Pain at origin of rectus abdominus Males > females PE: pain w adduction, pain w/ valsalva Tx: conservative Exertional compartment sx - Anterior compartment most often affected - May be ass w/ muscle hernia - > 30 mm Hg 1 min after exercise - resting > 15 mm Hg popliteal artery entrapment sx - medial head of gastroc aberration leads to constriction of artery - intermittent claudication, decreased pulses - Tx: medial head of gastroc release Saphenous neuritis - Surfer‟s neuropathy Entrapment of superficial peroneal N. - 12 cm prox to LM - fascial defect lateral plantar N. – baxter’s n. - trapped in abd hallicus fascia medial plantar N. - arch support aggravates sx Quadriceps contusion - Immobilize in flexion GCS Tennis leg – plantaris tendon Tx w/ conservative management - Sports hernia - Endoscopy? Rectus Femoris Tightness - Modified Thomas test Adductor Strain - Common in hockey Snapping hip - External – ITT over GT in flexion o Tx: conservative or z-plasty - Internal – extend hip from FABER (iliopsoas) o Tx: conservative or lengthening - Intra-articular o Labrum, loose body o Tx: hip arthroscopy Hip dislocation - 90% posterior - look for post acetabular fx on obturator oblique o aspirate hip if find (to relieve pressure) o then high risk of ON - 10-20% incidence of ON o MC complication GT bursitis - 60% respond to injection Hip arthroscopy - Anterolateral portal – superior gluteal nerve - Posterolateral – sciatic n. - Anterior LFC N > femoral N Medial tibial stress sx - Pain decreases w/ running - Distal pronation - Increased uptake in blood pool phase on bone scan Proximal hamstring avulsion - Water skiing injury - Avulsion off of ischial tuberosity - Tx: early repair Myositis ossificans - Tx: active, not passive ROM - Tx: rest Peroneal tendon injuries - Longitudinal tears usu involves brevis at fibular groove - Tx: debride/repair FHL tendon injury Sports Medicine Decreased great toe passive extension in neutral (nl in PF) Pain w/ resisted toe PF Posteromedial pain No pain w/ passive ankle plantar flexion Tx: ice, NSAIDs Glenohumeral joint - SGHL – inferior stability (arm adducted to side) - MGHL o Ant stability 45 deg, shoulder ER o Buford: variant o Poorly defined in 40% of pt - IGHLC o Anterior band – stabilizer w/ ABD/ER (cocking) o Post band – stabilizer w/ 90 deg flexion and IR  static post stabilizer o SLAP lesion doubles the strain in IGHLC - Labrum from 12 to 3 o‟clock is nl variant of “tears” or foramen - When shoulder is neutral, restraint is coracohumeral lig (ant-inf) o 90 deg flexion/IR, then IGHL o when in ER, then subscap M. - RTC dyn jt compression force more imp for stab than GH lig - Scapular stabilizers position glenoid in anteverted, sup position, dynamic coverage for retroverted hum head - Biceps tenson prov stab in ant and sup direction AC joint - Coracoclavicular ligaments – vertical tether - AC ligaments – horizontal tether Throwing - Wind-up - Early cocking - Late cocking o Internal impingement o Posterior glenoid tightness, partial cuff tears, glenohumeral internal rotation defects - Acceleration - Follow-through o Stresses post capsule o Ass w/ SLAP tears o Highest torque across glenohumeral joint Achilles tendon injuries - Tx: rest therapy w/ eccentric training later phases - In rupture, if defect > 5 cm, then FHL transfer - < 4 cm, then V-Y repair is appropriate - Up to 50% Achilles can be detached before detectable weakness Os trigonum - Surgical excision of lateral - Pain w/ passive ankle plantar flexion Os subfibulare - Avulsion fx ATFL - Ass w/ chronic ankle instab Os peroneum – in peroneus longus tendon near 5th MT base - Proximal location = PL rupture Ankle sprain - OR – Brostrom procedure – for refractory cases Ankle arthroscopy - Portals and dangers o AL: peroneus tertius, superficial peroneal n. o AM: TA, saphenous vein o PL: SSV/SN sural nerve o Risks: synovial cut fistula, NV risk Plantar fasciitis - Can be treated w/ shock wave tx Turf toe - Incompetent plantar sesamoid complex - Mechanism: hyperextension of MTP jt, axial loading of post hindft - Late sequela: hallux rigidus o Tx: cheilectemy Sports Medicine shoulder most susc to injury during late cocking and early acc phases o tensile and compressive forces peak, pathologic stresses on both areas Throwers o inc ER from inc humeral retroversion (occurs through physis in little league) or o inc ant lig laxity o GT fx Older patients (> 40) o RTC tear (need to repair this)  MC cause of recurrent instability  40% in pt > 60 yo o Nerve injury up to 50% Arthroscopic contraindicated w/ glenoid defects > 25% and engaging Hill-Sachs Lesions o higher recurrence rate o inc ER compared to open o engaging Hill-Sachs, inverted-pear glenoid ass w/ high rates of instab after arthro repair  engages in abd and ER Putti-platt o Ties up subscap o Wears out post glenoid o Arthritis as complication Bristow o Coracoid to glenoid transfer o Complication: nonunion Complications o Recurrence o Unrepaired labral tear o Subscap injury (from open shoulder procedures) o Axillary nerve injury  Exploration if no recovery @ 6-9 mo o Overtightening  Tx: z-lengthening of subscap o Late arthritis o Migrating hardware MDI o isometric M. act leads to off-center hum head in MDI  in traum instab – hum head centers o arthroscopic shrinkage in 27 shoulders w/ MDI – success rate of 82% poor results of revision: atraumatic causes of failure, voluntary dislocations, multiple prior stab attempts - - Posterior shoulder dislocation - Loss of external rotation - Jerk test – jerks back in with cross-abduction test Subscap tear - Excessive ER - Lift off test o Tests lower muscle (lower subscap N.) C5-6) - Abd compression test o Tests upper muscle (upper subscap N.) C5 Humeral avulsion of glenohumeral ligament - Older pt than Bankart - MRI shows inferior extravasation of MRI - Tx w/ open repair of lateral joint capsule Anterior instability - Bankart – avulsion of ant-inf capsulolabrum from ant-inf glenoid rim o West Point – reveal bony bankarts - Stretching of ant-inf capsulolabrum o in recurrent dislocaters, ant and inf capsule elongated average 20% - Throwers: shoulder slides out front during late cocking phase - 80-90% recurrence in young pt o but still – standard of tx is conservative management - Tx: splint in external rotation (initial tx) - Associated lesions o Labral-Bankart tear o Hill-Sachs defect  Stryker notch view shows this  80% ant instab have it  play sign role if 30% of prox hum art surf - - - - - Posterior instability - Throwers: shoulder sx on follow-through phase Sports Medicine Subluxates w/ IR, cross-body o reduction w/ further rotation Hypermobility of joints Need to address capsule Seizures/shock Exam: decreased ER Can do open reduction for chronic reduction even 3 mo after procedure Address reversed hill sachs defect o Need to fill w/ lesser tuberosity or allograft  Subscap and LT transfer for young pt  Defects 20-45% of head  Disimpaction & BG is option in injuries < 3 wks old o Hemiarthroplasty if too big Subluxation o Offensive lineman, pitchers o Tx: strengthen infraspinatus, avoid IR in bracing o If after 6 mo, fails, then tx:  Posterior capsular shift Problems w/ thermal shrinkage o High recurrence rate w/ shoulder instability (50% for MDI) o Capsular necrosis/ablation o Articular cartilage death o Axillary nerve injury o It breaks collagen cross-links, 65 degree C Art cuff surf - less vascular, higher mod of elast, higher ecc forces, less favorable stressstrain curve o MC to have art-sided tears than bursal RTC tear o Leads to superior translation of humeral head w/ 30 deg of abduction Biceps tendon o instab ass w/ subscap or ant interval tears o biceps tenotomy performed for massive tears - - - Os acrominale - Unfused secondary ossification center - Incidence 3% - Changes treatment o May need to fuse the os before decompression o Excision can lead to deltoid dysfunction o May need aggressive acromioplasty Subcoracoid impingement - Impingement of LT and coracoid w/ flexion and IR - Local anesthetic will eliminate sx - Nl coracohumeral distances o Adducted: 8.7 mm o Flexed: 6.8 mm RTC repair - Rehab: early PASSIVE ROM postop - w/ advanced cuff arthropathy – then hemiarthroplasty o not improve function, just pain - Tears easier to repair when smaller - Higher recurrence rate w/ large tears o repair predictable for pain relief, not strength - Chronic tears – M. atrophy, fatty degen - Tear size most imp determinant of outcome in active motion, strength, rating of result, pt satisfaction - Long-term outcome is good - Success in fx outcome and pain relief does not correlate w/ anatomic healing of RTC - Ant-sup instability - Rotator Cuff Dz - RTC purposes o keep hum head center on glenoid by counteracting sup vector of deltoid o add strength and dyn stab to GH motion - Amount of retraction and not just transv diameter – imp factor in fx def p RTC tear - U/S can dx full-thickness, partial-thickness tears - no correlation b/w degn XX changes and fullthickness tears - no ass b/w acromial pathology and RTC tears - Throwers: part-thickness art-sided tear of supra, and less so in infra Sports Medicine o massive tears, disruption of coracr arch, ant deltoid dehisc complications of operative tx o lateral acromionectemy o AC pain o Deltoid detachment (open > miniopen) Open repair w/ better strength, fx, outcome scores, but pt satisfaction comp w debridement T-x of pec major for irreparable subscap tear T-x latiss for post and sup cuff insuff Calcific tendonitis o Along supraspinatus tendon insertion o Tx: pt/aspiration o Surg evacuation of calcium deposits MC organism of infx: propionbacterium acnes RTC interval o Can be injured during surgery (develop ganglion) o Dx: RTC interval contracture w/ limited ER @ side o Tx: arthroscopic release Axillary/subclavian A aneurysm – painful ischemic hand in pitchers - Pec Major rupture - Exclusively in males - Weight lifters - Axillary webbing Subscap rupture - Hyperabduction/ER mechanism - Lift off test - Biceps displaced medial o Ass w/ disruption of transverse ligament - Need to stabilize biceps tenodesis along w/ subscap SLAP tears - I – fraying - II – detachment of superior labrum from glenoid o peel-back phenomenon, contrib. to post-sup instab o anatomic repair shown to eliminate the effect - III – nl intact anchor w/ displaced labrum - IV – displaced anchor - Superior labrum withstands ER forces - If 50% detachment of biceps, then tenodesis of biceps tendon - repair – 90% return to preinjury level Glenohumeral internal rotation deficit - Increased humeral retrovesion w/ scapula stabilized - > 20 deg loss IR is diagnostic - Pitchers - Tx: sleeper stretcher (internal rotation – push) o Need 6 mo before operation – post capsular release Internal impingement - Entrapment of post sup RTC/labrum during late cocking/early acceleration - Partial articular sided cuff tear at junction of SS and IS o b/c SS abrades against post superior glenoid - MRA w/ abd-ER rotation view - - - Suprascapular neuropathy - SS notch entrapment o Transverse scapular ligament (hypertrophic) - underneath o Affects supra and infraspinatus o Decompress open - Spinoglenoid notch entrapment o Affects infraspinatus only o Ass w/ post SLAP and cyst o Traction injury in volleyball - EMG/NCS is diagnostic Quadrilateral space sx - sx caused by compression of ax nerve - Tx: open decompress of quad space Thoracic outlet syndrome - More common in females - Tx: remove cervical rib, scalene muscle Shoulder destruction - Neuropathic joint o Syringomyelia o Hansen‟s disease Sports Medicine o reveals post-sup labrum abn w/ “kissing lesion” of art-sided RTC Tx: post capsular stretch/strengthen, or arthroscopic debridement o avoid hyperangulation – shoulder extension beyond plane of scapula during cocking phase o arthroscopic tx focus on debridement of RTC tear, post glenoid labral lesion o last resort: humeral derotational osteotomy  goal: postop hum retrov of 30 deg  compl rate high (hdwr) Non-surgical tx - Adhesive capsulitis - Pain w/ decreased ROM - Ass w/ autoimmune dz - Rehab, rehab, rehab for months - MUA for late treatment - Essential lesion o Coracohumeral lig and rotator interval capsule Scapular winging - Based on inferior border of scapula o Medial: Compression of long thoracic nerve o Give 6 mo for nerve to come back o Tx: pec transfer - Lateral winging o Trapezius, CN XI o Tx: fuse scapula to thorax, or Eden Lange Transfer: t-x medial scapular muscles (levator and rhomboids) laterally Little leaguer’s shoulder - Type I SH to proximal humerus - XX: widened proximal physis - Curve ball implicated - Tx: rest for 12 wks Clavicle Fx - Operative indications o Open fx o Subclavian A injury o Floating shoulder – clavicle & scapula neck fx o Type II distal fx o Sx: nonunion Concussion - 3 in a year o season is terminated biceps tendon rupture - MC injured NV structure: lateral antebrachial cutaneous N. - Synostosis is common complication, worse w/ approaches involving ulna Bennett Lesion - Glenoid exostosis - Ass w/ internal impingement (baseball players) Posterior SLAP tear - Accentuated with „peel back‟ w/ shoulder abduction - Posterior labral attachment o Common in football lineman o Tx: labral repair Distal clavicle osteolysis - MOI: weight lifters - XX: cysts/osteopenia - Tx: distal clav resection AC arthritis - Tx: activity modification, injection - Distal clav resection SC injury - Serendipity view, or CT - Anterior instability o Chronic: IGNORE o Acute: reduce - Post instability: closed reduction - Posterior capsular ligament o Most important structure for A/P stability - Avoid pins/hdwr for fixation Latissimus Dorsi Tear - Weakness in extension Sports Medicine Distal radius physeal stress Sx - Gymnasts - Tx: 3-6 mo of rest Elbow arthroscopy - MC palsy: ulnar N. palsy Elbow stability - LCL resists both varus and ER stresses - MCL divided 3 segm: ant bund, post bund, transverse segm o stab structure to valgus o overhead throwers w/ MCL inj dev posteromed olecranon impingement, ulnohum arthritis with cont throwing o 40% pt req MCL recon have ulnar N. sx o 70% throwers w/ MCL recon back to sport - Little Leaguer‟s Elbow o on medial side, medial epicondyle growth plate is weaker, more susc to trauma than MCL OCD in elbow - rep compression loads leads to focal ON of capitellum or radial head - OCD of capitellum seen in athletes 13-15 yo Elbow arthroplasty - Unconstrained elbow arthroplasty o 10% w/ instability - Distraction interposition ulnohumeral arthroplasty o Tx for pt w/ RA and posttraumatic OA o And young pt who cannot have total elbow, high-demand pt - OA best tx w/ ulnohumeral arthroplasty Erb’s palsy in baby - Can resolve up to 2 yr after birth Stress in elbow (in extension) - 40% ulnohumeral - 60% radiohumeral