2015 Sports Flashcards
Question 11
A professional basketball player underwent anterior cruciate ligament reconstruction and is going through
an uneventful postsurgical rehabilitation. He would like to know how his return to play will be evaluated.
The ideal method with which to determine the timing of his return should involve which factors?
1. Time since his reconstruction
2. Consultation with the team owner
3. The surgeon’s rehabilitation protocol
4. Discussion with the team’s athletic trainer and physical therapist
5. Stipulations in the player’s contract regarding the percentage of games played
- Discussion with the team’s athletic trainer and physical therapist
This question is to highlight the difficulty in assessing return to play and how it involves many parties. 2 and 5 are clearly wrong. 1 and 3 are only to the surgeon’s opinion so that’s what they are getting to is wrong (more people are involved).
Second article:
A lot of times people disagree on the decision, but it is most important that the decision must be made in “do no harm” fashion to the athlete, and accounting for many factors (level of competition, etc.) which is individualized, so the answer is 4.
The first article states that based on people surveyed (therapists, physicians, coaches, athletes), that medical doctors, physiotherapists and athletic therapists were the best to make the return to play decision. However, every clinician thought their own were the most important…
Neither of the articles talk about the time since reconstruction
RECOMMENDED READINGS
Shrier I, Safai P, Charland L. Return to play following injury: whose decision should it be? Br J Sports
Med. 2014 Mar;48(5):394-401. doi: 10.1136/bjsports-2013-092492. Epub 2013 Sep 5. PubMed PMID:
24009011.
Clover J, Wall J. Return-to-play criteria following sports injury. Clin Sports Med. 2010 Jan;29(1):169-75,
table of contents. doi: 10.1016/j.csm.2009.09.008. PubMed PMID: 19945592.
Question 23
Figures 23a through 23c are the clinical photographs of a 52-year-old tennis player who has lateral
shoulder pain with activity and difficulty with his serve. (images show medial scapular winging). Examination reveals pain resolution during a
scapular assistance test. What is the most appropriate initial treatment of this patient’s condition?
1. Scapulothoracic fusion
2. Transfer of the levator scapulae and rhomboid muscles
3. Exploration of the spinal accessory nerve
4. Decompression of the long thoracic nerve
5. Pectoralis stretching and strengthening of rhomboids, serratus, and trapezius
- Pectoralis stretching and strengthening of rhomboids, serratus, and trapezius
Let’s see… 4 operative treatments for a 52 year old tennis player vs nonop… no brainer.
First article: “Although most cases resolve nonsurgically, surgical treatment of scapular winging has been met with success”
RECOMMENDED READINGS
Meininger AK, Figuerres BF, Goldberg BA. Scapular winging: an update. J Am Acad Orthop Surg. 2011
Aug;19(8):453-62. Review. PubMed PMID: 21807913.
Kibler WB, Sciascia A, Wilkes T. Scapular dyskinesis and its relation to shoulder injury. J Am Acad
Orthop Surg. 2012 Jun;20(6):364-72. doi: 10.5435/JAAOS-20-06-364. Review. PubMed PMID:
22661566.
Question 42
Figures 42a and 42b are the MR images (ACL tear and posterolateral injury) of an 18-year-old collegiate football player who landed
awkwardly after jumping to defend a pass. He reported a buckling sensation in his left knee and required
assistance of the field. Knee examination reveals an increase in translation during a Lachman test but
a feeling of an end point. He has mild varus laxity without a palpable lateral collateral ligament (LCL).
What is the most appropriate treatment option?
1. LCL repair
2. LCL repair with augmentation
3. Anterior cruciate ligament (ACL) reconstruction with an Achilles allograft
4. ACL reconstruction and posterolateral corner reconstruction
5. Rehabilitation and bracing to continue play with surgical treatment after the season
- ACL reconstruction and posterolateral corner reconstruction
This question highlights the importance of acute repair of posterolateral corner injuries (which is better than chronic), and also to recognize a posterolateral injury (and not just fix the ACL) since it is likely to cause the ACL reconstruction fail.
“Posterolateral corner injury, an increasingly recognized entity, is commonly associated with concomitant ligament disruptions. Prompt recognition is critical for several reasons. Missed posterolateral corner injuries increase the failure rates for both anterior and posterior cruciate ligament reconstructions. Also, untreated posterolateral corner injuries lead to chronic disability. Acute (ie, immediate) surgical intervention results in superior outcomes compared with chronic (ie, late) reconstruction. Although no universal classification system has been adopted, attention to both varus and rotational stability is critical. Multiple options exist for posterolateral corner reconstruction, although recent trends have shifted toward anatomic reconstruction techniques.”
RECOMMENDED READINGS
Ranawat A, Baker CL 3rd, Henry S, Harner CD. Posterolateral corner injury of the knee: evaluation and
management. J Am Acad Orthop Surg. 2008 Sep;16(9):506-18. Review. PubMed PMID: 18768708.
Engelman GH, Carry PM, Hitt KG, Polousky JD, Vidal AF. Comparison of allograft versus autograft
anterior cruciate ligament reconstruction graft survival in an active adolescent cohort. Am J Sports Med.
2014 Oct;42(10):2311-8. doi: 10.1177/0363546514541935. Epub 2014 Jul 31. PubMed PMID: 25081312.
Question 51
Figures 51a through 51e are the radiographs (Hill Sachs), MR image (labral tear), and CT scans (anterio-inferior glenoid bone loss) of a 25-year-old man who has
had right shoulder instability for 6 years. He had an initial episode while playing basketball and a second
episode a few years later (also while playing basketball). Both injuries were anterior glenohumeral
dislocations that necessitated reduction. Currently he feels instability with simple maneuvers and
overhead activities. Examination reveals apprehension with abduction and external rotation and relief
with posterior-directed force on the proximal humerus in this position. A strengthening program has not
provided adequate stability. What is the best treatment option?
1. Shoulder arthroscopy with rotator cuf repair
2. Shoulder arthroscopy with superior labral repair
3. Shoulder arthroscopy with anterior labral repair and capsulorrhaphy
4. Shoulder stabilization procedure to address glenoid bone loss
5. Continued physical therapy and a shoulder stabilization exercise program
- Shoulder stabilization procedure to address glenoid bone loss
Basically they want you to recognize there is significant glenoid bone loss so you can’t do a Bankart repair.
1st and 3rd study looked at patients with/without bone loss doing arthroscopic/open bankart repair. Essentially they found arthroscopic = open repairs if there is no bone loss, but that you can’t do an arthroscopic repair if there is bone loss (inverted-pear Bankart lesion, or engaging Hill-Sachs). If there is a large bone defect, they suggest considering bone reconstruction procedure (ex: Latarjet).
2nd study looked at how much bone loss you can accept. The cutoff is 21 degrees. >21 degrees you need to address the bony defect (otherwise you get instability at extremes of ROM).
RECOMMENDED READINGS
Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of
arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill
Sachs lesion. Arthroscopy. 2000 Oct;16(7):677-94. PubMed PMID: 11027751.
Itoi E, Lee SB, Berglund LJ, Berge LL, An KN. The effect of a glenoid defect on anteroinferior stability of
the shoulder after Bankart repair: a cadaveric study. J Bone Joint Surg Am. 2000 Jan;82(1):35-46. PubMed
PMID: 10653082.
Burkhart SS, De Beer JF, Barth JR, Cresswell T, Roberts C, Richards DP. Results of modified Latarjet
reconstruction in patients with anteroinferior instability and significant bone loss. Arthroscopy. 2007
Oct;23(10):1033-41. Erratum in: Arthroscopy. 2007 Dec;23(12):A16. Criswell, Tim [corrected to
Cresswell, Tim]. PubMed PMID: 17916467.
Question 83
A 17-year-old football player is hit during the course of play. He lies down on the field as the training staff
enters the field to assist. By the time they arrive to the player, he is sitting up. He quickly stands and is
walked to the sideline. The player experiences initial confusion when questioned on the sideline, but this
quickly passes. He has no memory loss; is alert and oriented to person, place, and time; and has a mild
headache. He wants to return to the game and the coach asks if he can play. What is the best next step?
1. No return to play this game
2. Immediate return to the game
3. Obtain an immediate head CT scan
4. Return to the game only if the team’s needs necessitate it
5. Return to the game when his headache symptoms resolve
- No return to play this game
Essentially this is the most important thing to know of concussions when being a team physician - recognize a concussion and DO NOT let the athlete return to play that game until going through the appropriate concussion return to play guidelines.
Mechanism in keeping with a head injury + signs of brain neurological symptom/sign= assume concussion and withdraw the athlete from play to avoid second impact syndrome (2nd concussion close to the first one) cause their brain can swell and there is an extremely high mortality associated with it.
Although his confusion quickly improved, he had confusion = neuro symptom= concussion = no return to play.
FYI: headache counts as a “neuro symptom”
RECOMMENDED READINGS
McCrory P, Meeuwisse WH, Aubry M, Cantu B, Dvorák J, Echemendia RJ, Engebretsen L, Johnston
K, Kutcher JS, Raftery M, Sills A, Benson BW, Davis GA, Ellenbogen RG, Guskiewicz K, Herring
SA, Iverson GL, Jordan BD, Kissick J, McCrea M, McIntosh AS, Maddocks D, Makdissi M, Purcell
L, Putukian M, Schneider K, Tator CH, Turner M. Consensus statement on concussion in sport: the 4th
International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013
Apr;47(5):250-8. doi: 10.1136/bjsports-2013-092313. PubMed PMID: 23479479.
Putukian M. The acute symptoms of sport-related concussion: diagnosis and on-fild management.
Clin Sports Med. 2011 Jan;30(1):49-61, viii. doi: 10.1016/j.csm.2010.09.005. Review. PubMed PMID:
21074081.
Question 99
A 26-year-old professional football player is experiencing sharp stabbing pain that radiates from his
neck to his left thumb. The pain began acutely after a tackle. An MR image of the cervical spine reveals
a lateral disk herniation with foraminal encroachment but no abutment of the cervical cord or central
stenosis. Which treatment most likely will allow an expedient return to play?
1. Cervical foraminotomy
2. Cervical disk replacement
3. Oral methylprednisolone
4. Chiropractic manipulation
5. Anterior cervical decompression and fusion
- Oral methylprednisolone
1st study is a small NFL study (16 patients).
8/16 returned to play after non-op management.
1/16 returned to play after ACDF.
5/16 did not return to play after non-op management.
2/16 did not return to play after surgery
Pretty heterogeneous population in terms of the severity of their injuries (more severe = needed surgery) so I am not sure you can conclude that surgery = longer return to sports, but definitely for this patient surgery is not indicated so the non-operative (non-chiropractic) answer is the right one.
Both articles don’t really talk about oral steroids.
“Data regarding the treatment of this unique population are limited but suggest that NFL athletes can safely return to sport after the treatment of cervical disc herniations. In the treatment algorithm for this study, cord compression with signal change in the cord on MRI was a consistent operative indication. Discs abutting the cord can be treated nonoperatively but do not allow for return to sport until symptoms have improved and repeat imaging demonstrates no cord compression. Isolated nerve root compression has a more favorable prognosis. It can be treated symptomatically and return to sport allowed when symptoms permit.”
2nd article is a review of literature that shows that there was complete resolution of symptoms in 83% of patients in 24-36 months (all comers - not just athletes)
RECOMMENDED READINGS
Meredith DS, Jones KJ, Barnes R, Rodeo SA, Cammisa FP, Warren RF. Operative and nonoperative
treatment of cervical disc herniation in National Football League athletes. Am J Sports Med. 2013
Sep;41(9):2054-8. doi: 10.1177/0363546513493247. Epub 2013 Jun 20. PubMed PMID: 23788681.
Wong JJ, Côté P, Quesnele JJ, Stern PJ, Mior SA. The course and prognostic factors of symptomatic
cervical disc herniation with radiculopathy: a systematic review of the literature. Spine J. 2014 Aug
1;14(8):1781-9. doi: 10.1016/j.spinee.2014.02.032. Epub 2014 Mar 12. PubMed PMID: 24614255.
Question 112
At the request of his parents, a 12-year-old Little League player is being evaluated for shoulder and elbow
pain in his pitching arm. He plays baseball through the spring, summer, and fall. When he is not playing
for multiple teams, he works with a pitching coach, throwing 3 to 4 days a week. He throws fastballs, a
change-up, and recently began throwing a curveball. With regard to his shoulder and elbow pain, what is
the most appropriate advice?
1. Throwing the curveball causes his pain, so be sure to inform his pitching coach.
2. Not pitch for at least 4 months out of the year.
3. Increase the time he spends with his pitching coach.
4. Begin a weight-lifting program for his shoulder and elbow.
5. Ulnar collateral ligament (UCL) reconstruction to address his elbow mechanics.
- Not pitch for at least 4 months out of the year.
Basically this is an overuse injury to his MUCL that requires a period of rest.
1st study showed that pitchers that had injury were associated with overuse, fatigue, high pitch velocity and participation in showcases.
2nd study just states that you can get MUCL injuries from over-pitching..
RECOMMENDED READINGS
Olsen SJ 2nd, Fleisig GS, Dun S, Loftice J, Andrews JR. Risk factors for shoulder and elbow injuries in
adolescent baseball pitchers. Am J Sports Med. 2006 Jun;34(6):905-12. Epub 2006 Feb 1. PubMed PMID:
16452269.
Bruce JR, Andrews JR. Ulnar collateral ligament injuries in the throwing athlete. J Am Acad Orthop Surg.
2014 May;22(5):315-25. doi: 10.5435/JAAOS-22-05-315. Review. PubMed PMID: 24788447.
Question 125
A 43-year-old marathon runner has pain deep in her buttocks. She has pain with running and difficulty
sitting on hard surfaces because of her pain at the ischium. She slipped on ice almost 1 year ago and
believes this was when her pain started. An MR image of the hip reveals a partial avulsion of the proximal
hamstring origin. She has been doing appropriate physical therapy since her injury occurred but has not
experienced symptom relief. What is the most appropriate treatment option?
1. Percutaneous tenotomy
2. Cessation of distance running
3. Use of a foam roller in therapy
4. Open debridement and repair
5. Administration of an oral corticosteroid
- Open debridement and repair
Essentially, operative repair has better outcomes than non-op for proximal hamstring avulsions.
1st study: average age 43 year old athletes. Post debridement and repair, all returned to sports, and all but 1/17 had improved symptoms.
2nd study: Nonsurgical management after a complete proximal hamstring avulsion yields noticeable subjective and strength deficits
RECOMMENDED READINGS
Bowman KF Jr, Cohen SB, Bradley JP. Operative management of partial-thickness tears of
the proximal hamstring muscles in athletes. Am J Sports Med. 2013 Jun;41(6):1363-71. doi:
10.1177/0363546513482717. Epub 2013 Apr 10. PubMed PMID: 23576684.
Hofmann KJ, Paggi A, Connors D, Miller SL. Complete Avulsion of the Proximal Hamstring Insertion:
Functional Outcomes After Nonsurgical Treatment. J Bone Joint Surg Am. 2014 Jun 18;96(12):1022-1025.
[Epub ahead of print] PubMed PMID: 24951738.
Question 146
A 20-year-old collegiate football player is seen after season completion with midfoot pain and bone scan
findings consistent with a navicular stress fracture. What is the most effective treatment option?
1. Rest from running, but no immobilization
2. Placement in a cast with no weight bearing for 2 weeks
3. Placement in a cast with no weight bearing for 6 weeks
4. Placement in a fracture boot with weight bearing as tolerated
5. Open debridement of the fracture site with internal fiation
- Placement in a cast with no weight bearing for 6 weeks
Non-weightbearing conservative management should be considered the standard of care for tarsal navicular stress fractures. There is no advantage for surgical treatment compared with NWB immobilization. However, there was a statistical trend favoring NWB over surgery. Rest or immobilization with weightbearing was inferior to both other treatments analyzed. The authors concluded that conservative NWB management is the standard of care for initial treatment of both partial and complete stress fractures of the tarsal navicular.
The other study found that clinical practice of stress fractures in reality differs from what is supported by evidence (see above), and that this is associated with a worse return to sports at the same level.
RECOMMENDED READINGS
Torg JS, Moyer J, Gaughan JP, Boden BP. Management of tarsal navicular stress fractures: conservative
versus surgical treatment: a meta-analysis. Am J Sports Med. 2010 May; 38(5):1048-53. doi:
10.1177/0363546509355408. Epub 2010 Mar 2. PubMed PMID: 20197494.
Burne SG, Mahoney CM, Forster BB, Koehle MS, Taunton JE, Khan KM. Tarsal navicular stress injury:
long-term outcome and clinicoradiological correlation using both computed tomography and magnetic
resonance imaging. Am J Sports Med. 2005 Dec;33(12):1875-81. Epub 2005 Sep 12. PubMed PMID:
16157855.
Question 159
An 18-year-old freshman is seen for her preparticipation lacrosse physical. She reports a history of asthma
but says that the albuterol inhaler that she was prescribed does not effectively clear her symptoms. She
has difficulty with breathing only during conditioning workouts, practices, and games. What is the most
appropriate recommendation for this athlete?
1. Refer her for confirmation of her asthma diagnosis
2. Initiate a course of oral steroids
3. Add a steroid inhaler
4. Add nebulizer treatments
5. Disqualify her from participation
- Refer her for confirmation of her asthma diagnosis
This question tests whether or not you know what EILO is (Exercise-induced laryngeal obstruction)
Essentially it’s a common condition usually misdiagnosed as asthma (that doesn’t respond to bronchodilators). For this reason, you should refer them for diagnosis to see whether or not they truly have asthma before starting more asthma medications.
Also, F*** managing asthma yourself. You want to be an orthopaedic surgeon right?
The second study is a meta-analysis supporting that exercise training improves asthma symptoms (therefore do not disqualify her from participation)
RECOMMENDED READINGS
Nielsen EW, Hull JH, Backer V. High prevalence of exercise-induced laryngeal obstruction in athletes.
Med Sci Sports Exerc. 2013 Nov;45(11):2030-5. doi: 10.1249/MSS.0b013e318298b19a. PubMed PMID:
23657163.
Eichenberger PA, Diener SN, Kofmehl R, Spengler CM. Effcts of exercise training on airway
hyperreactivity in asthma: a systematic review and meta-analysis. Sports Med. 2013 Nov;43(11):1157-70.
doi: 10.1007/s40279-013-0077-2. Review. PubMed PMID: 23846823.
Question 171 What is the best reason to use an autograft (rather than an allograft) for anterior cruciate ligament (ACL) reconstruction in a young athlete? 1. Lower infection risk 2. Lower graft rupture rate 3. Lower long-term risk for arthritis 4. Lack of donor-site morbidity 5. Better incorporation of the graft material
- Lower graft rupture rate
The first study looked at 281 ACLR and found that younger age and allograft had the highest rupture rate. Allograft rupture rate was 4x higher than autograft reconstructions.
Second study showed allograft was much more likely to rupture (odds ratio of 5.03)
Answer 4 and 5 make no sense and can be eliminated
RECOMMENDED READINGS
Kaeding CC, Aros B, Pedroza A, Pifel E, Amendola A, Andrish JT, Dunn WR, Marx RG, McCarty
EC, Parker RD, Wright RW, Spindler KP. Allograft Versus Autograft Anterior Cruciate Ligament
Reconstruction: Predictors of Failure From a MOON Prospective Longitudinal Cohort. Sports Health.
2011 Jan;3(1):73-81. PubMed PMID: 23015994; PubMed Central PMCID: PMC3445196.
Krych AJ, Jackson JD, Hoskin TL, Dahm DL. A meta-analysis of patellar tendon autograft versus patellar
tendon allograft in anterior cruciate ligament reconstruction. Arthroscopy. 2008 Mar;24(3):292-8. doi:
10.1016/j.arthro.2007.08.029. Epub 2007 Nov 5. Review. PubMed PMID: 18308180.
Question 181
Figures 181a and 181b are the arthroscopic views of an 18-year-old collegiate basketball player who has
recurrent effusions 9 months after his fourth patella dislocation. He has had bracing and physical therapy
since the previous dislocation. Radiographs reveal lateral congruence. MR imaging shows articular
cartilage loss in the inferolateral patella. Lateral tibial tubercle offset relative to the trochlea groove is 19
mm. Diagnostic arthroscopy figures show the patella before and after debridement (severe articular cartilage injury and fraying, then debrided). An articular cartilage
biopsy is obtained. Reimplantation of articular cartilage should be undertaken in conjunction with which
other procedure(s)?
1. Galeazzi realignment
2. Anteromedial tibial tubercle transfer
3. Vastus medialis oblique (VMO) advancement
4. VMO advancement and lateral release
5. Medial tibial tubercle transfer and lateral release
- Anteromedial tibial tubercle transfer
The key is recognizing that the goal here is to offload the inferolateral patella since it has severe cartilage loss. The first study found that antero-medialization of the tibial tubercle decreased contact forces of the patella on the lateral femoral condyle and increased them on the medial femoral condyle. Therefore it is indicated for LATERAL patella cartilage loss (minimal effect for central defect, actually bad to do this if you have medial defect - which makes sense).
2nd study just says that operative treatment is indicated if a patient fails conservative management. Microfracture, chondrocyte implantation, osteochondral autograft transfer, osteochondral allograft are all options depending on size, location, underlying subchondral bone… They also suggest the literature says combining this with a tibial tubercle osteotomy to offload the defect is indicated.
TT-TG cutoff >20mm
RECOMMENDED READINGS
Beck PR, Thomas AL, Farr J, Lewis PB, Cole BJ. Trochlear contact pressures after anteromedialization
of the tibial tubercle. Am J Sports Med. 2005 Nov;33(11):1710-5. Epub 2005 Aug 10. PubMed PMID:
16093531.
Strauss EJ, Galos DK. The evaluation and management of cartilage lesions affcting the patellofemoral
joint. Curr Rev Musculoskelet Med. 2013 Jun;6(2):141-9. doi: 10.1007/s12178-013-9157-z. PubMed
PMID: 23392780; PubMed Central PMCID: PMC3702778.
Question 184
Which effect does initiation of early eccentric strengthening at 3 weeks from surgery have in rehabilitation of anterior cruciate ligament (ACL) reconstruction compared to traditional initiation at 3 months?
1. Improved control of postsurgical effusion
2. Increased pain in the surgical extremity
3. Increased muscle mass of the quadriceps and hamstrings
4. Increased risk for graft loosening because the tunnels have not healed
5. Decreased risk for rupture of the contralateral ACL
- Increased muscle mass of the quadriceps and hamstrings
You can eliminate 2 and 4 because they are negative (and the question is clearly looking for a beneficial thing compared to traditional)
1st study: systematic review: range-of-motion, strengthening, and functional exercises are important for post-ACL reconstruction rehab
2nd study: systematic review: the results clearly indicated that an accelerated protocol WITHOUT postoperative bracing, in which reduction of pain, swelling and inflammation, regaining range of motion, strength and neuromuscular control are the most important aims, has important advantages and does not lead to stability problems
3rd study: randomized matched-trial. This is where the money’s at for this question!! Negative (eccentric) work was implemented safely after ACL-R. The addition of negative work exercise also induced superior short-term results in strength, performance, and activity level after surgery.
RECOMMENDED READINGS
Kruse LM, Gray B, Wright RW. Rehabilitation after anterior cruciate ligament reconstruction: a systematic
review. J Bone Joint Surg Am. 2012 Oct 3;94(19):1737-48. doi: 10.2106/JBJS.K.01246. Review. PubMed
PMID: 23032584; PubMed Central PMCID: PMC3448301.
van Grinsven S, van Cingel RE, Holla CJ, van Loon CJ. Evidence-based rehabilitation following anterior
cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2010 Aug;18(8):1128-44. doi:
10.1007/s00167-009-1027-2. Epub 2010 Jan 13. Review. PubMed PMID: 20069277.
Gerber JP, Marcus RL, Dibble LE, Greis PE, Burks RT, Lastayo PC. Safety, feasibility, and efficy of
negative work exercise via eccentric muscle activity following anterior cruciate ligament reconstruction. J
Orthop Sports Phys Ther. 2007 Jan;37(1):10-8. PubMed PMID: 17286094.
Question 188
A 20-year-old dancer has atraumatic onset of midfoot pain. Radiographic fidings are normal. Her body
mass index is 18.5, and she has had 5 menstrual cycles during the past year. What is the long-term risk of
no treatment?
1. Secondary infertility
2. Functional hyperthyroidism
3. Rebound uterine hypertrophy
4. Secondary calcium defiiency
5. Irreversible loss of bone mineral density
- Irreversible loss of bone mineral density
This is testing your knowledge of the “female athlete triad” = osteoporosis, anorexia, amenorrhea.
The recommended articles says you need a multidisciplinary approach to deal with these athletes. No supplement has been shown to for sure help with BMD, but optimizing vit d/calcium should be one. It quotes a paper that states that amenhorreic athletes have irreversible loss of BMD (Article name: Irreversible bone loss in former amenorrheic athletes) - this isn’t a great study design and has a small sample size… But anyways this is what they want you to know!
Could have sworn I learned in med school that the amenorrhea can be permanent, but can’t find any evidence that it is - so I am probably recalling wrong.
RECOMMENDED READINGS
Nazem TG, Ackerman KE. The female athlete triad. Sports Health. 2012 Jul;4(4):302-11. PubMed PMID:
23016101; PubMed Central PMCID: PMC3435916.
Nattiv A, Loucks AB, Manore MM, Sanborn CF, Sundgot-Borgen J, Warren MP; American College of
Sports Medicine. American College of Sports Medicine position stand. The female athlete triad. Med Sci
Sports Exerc. 2007 Oct;39(10):1867-82. PubMed PMID: 17909417.
Question 201
Figures 201a through 201f are the radiographs and MR images of a 64-year-old woman who has left
shoulder pain. She has had the pain “on and off” and it mostly bothers her at night. She has been taking
anti-inflammatory pain medications and has experienced some relief. Examination reveals mildly
diminished range of motion in elevation and external rotation, and she reports moderate pain with forced
abduction of the shoulder. Her strength in elevation is 4/5, which is limited by pain, and her external
rotation strength is 5/5. She has a negative belly press sign. What is the most appropriate next step?
1. Injection of platelet-rich plasma to the subacromial space
2. A 6-week course of physical therapy
3. Arthroscopic capsular release with manipulation under anesthesia
4. Arthroscopic subacromial decompression with coracoacromial ligament release
5. Arthroscopic rotator cuf repair
- A 6-week course of physical therapy
Basically this elderly lady had a RCT and has not tried physical therapy yet.
The first study showed that PRP is not helpful : “At 1-year follow-up, a PRP injection was found to be no more effective in improving quality of life, pain, disability, and shoulder range of motion than placebo in patients with chronic RCT who were treated with an exercise program.”
The second article cautions the use of PRP until we have more evidence. (therefore 1. is wrong)
The third article is an RCT for acromioplasty vs. physio alone, which shows no difference between the groups (therefore 4. is wrong)
The fourth article: moderate grade recommendations:
- NSAID + exercise is indicated in the absence of full RTC
- Routine acromioplasty is not required at time of RTC repair
- can use porcine xenograft patches
- worker’s comp = worse outcome after surgery
RECOMMENDED READINGS
Kesikburun S, Tan AK, Yilmaz B, Yaşar E, Yazicioğlu K. Platelet-rich plasma injections in the treatment
of chronic rotator cuf tendinopathy: a randomized controlled trial with 1-year follow-up. Am J Sports
Med. 2013 Nov;41(11):2609-16. doi: 10.1177/0363546513496542. Epub 2013 Jul 26. PubMed PMID:
23893418.
Hall MP, Band PA, Meislin RJ, Jazrawi LM, Cardone DA. Platelet-rich plasma: current concepts and
application in sports medicine. J Am Acad Orthop Surg. 2009 ct;17(10):602-8. Review. Erratum in: J Am
Acad Orthop Surg. 2010 Jan;18(1):17A. PubMed PMID: 19794217.
Ketola S, Lehtinen J, Arnala I, Nissinen M, Westenius H, Sintonen H, Aronen P, Konttinen YT,
Malmivaara A, Rousi T. Does arthroscopic acromioplasty provide any additional value in the treatment
of shoulder impingement syndrome?: a two-year randomised controlled trial. J Bone Joint Surg Br. 2009
Oct;91(10):1326-34. doi: 10.1302/0301-620X.91B10.22094. PubMed PMID: 19794168.
Pedowitz RA, Yamaguchi K, Ahmad CS, Burks RT, Flatow EL, Green A, Iannotti JP, Miller BS, Tashjian
RZ, Watters WC 3rd, Weber K, Turkelson CM, Wies JL, Anderson S, St Andre J, Boyer K, Raymond
L, Sluka P, McGowan R; American Academy of Orthopaedic Surgeons. Optimizing the management of
rotator cuf problems. J Am Acad Orthop Surg. 2011 Jun;19(6):368-79. PubMed PMID: 21628648.
