Soft Tissue

Question 1

What is tennis and golfers elbow?

Answer 1

Pain at the tendon insertion or myotendinous junction of these muscle groups is referred to as….
a) Lateral elbow tendinopathy (LET) – Tennis elbow - wrist extensors
b) Medial elbow tendinopathy (MET) – Golders elbow - wrist flexors

Underlying causes are unknown – however, we are able to identify pathological changes in the tendon origins

Question 2

What are the risk factors for tennis and golfers elbow?

Answer 2

Risk factors…
a) Smoking
b) Obesity
c) Age 45 to 54
d) Repetitive movement for at least two hours daily
e) Forceful activity (managing physical loads over 20 kg)

Question 3

What factors are linked to a poor prognosis for tennis and golfers elbow?

Answer 3

Factors that correlate with a poor prognosis…
a) High physical strain at work
b) Dominant side involvement
c) Concomitant neck pain
d) Duration of symptoms greater than three months
e) Severe pain at presentation

Question 4

What is the epidemiology and risk factors for lateral (tennis) elbow tendinopathy?

Answer 4

• Most common injury in tennis
• Risk increases with age
• Risk of injury is 2-4 times larger in players playing more than 2 hours a day
• More common in recreational players rather than advanced – differences in technique

Question 5

What is the epidemiology and risk factors for Medial (golfers) elbow tendinopathy?

Answer 5

• 90% of golfers elbow cases occur outside sports participation
• Occupational settings involving forceful gripping is particularly associated with MET
• Women are more likely than men to suffer from MET
• Three of four cases involve the dominant arm
• Sports – associated with repetitive forceful forearm pronation and wrist flexion

Question 6

The tendons of which muscles are commonly overused in tennis elbow?

Answer 6

Overuse injury involving the proximal tendons of the extensor carpi radialis brevis and occasionally the extensor digitorum communis muscle constitutes LET

Question 7

The tendons of which muscles are commonly overused in golfers elbow?

Answer 7

Overuse injury involving the proximal tendons of the pronator teres and flexor carpi radialis muscles causes medial elbow tendinopathy (MET).

Question 8

What is the underlying pathophysiology of elbow tendinopathy?

Answer 8

Elbow tendinopathy represents a chronic tendinosis, rather than an acute inflammatory process, involving disorganized tissue and neovessels within the involved tendon

Targeting this degenerative tendinosis and neovascularization is the focus of emerging treatments

Question 9

What are the general mechanisms of injury associated with elbow tendinopathy?

Answer 9

• Repetitive athletic movements, particularly those performed rapidly and forcefully, involving eccentric motion in which a muscle-tendon unit is lengthened while under a load, may increase susceptibility to injury.
• May be due to improper technique or equipment or otherwise due to inadequate strength, endurance, or mobility.
• Occupational injuries – repetitive movements where wrist frequently deviates from a neutral position + dose-dependent relationship between regularly handling load over 20Kg and development of tendinopathy.

Question 10

How do patients with elbow tendinopathy present?

Answer 10

• Patients with elbow tendinopathy typically complain of extra-articular medial or lateral elbow pain.
• Patients may have had symptoms for only a few weeks, but others may have symptoms that persist for many months or longer.
• Pain severity can range from minimal, with which patients continue to participate in work or sport, to severe, interfering with even basic daily tasks and sleep.

Question 11

How is lateral and medial elbow tendinopathy diagnosed?

Answer 11

Lateral elbow tendinopathy (LET) is diagnosed clinically by the following findings:
a) Localized tenderness over the lateral epicondyle and proximal wrist extensor muscle mass
b) Pain with resisted wrist extension with the elbow in full extension
c) Pain with passive terminal wrist flexion with the elbow in full extension (Mill’s test)
d) Pain in the extensor compartment upon the resisted supination of the wrist
- Can also use the book test and tennis elbow test

Medial elbow tendinopathy (MET) is diagnosed clinically by the following findings:
a) Localized tenderness over the medial epicondyle and proximal wrist flexor muscle mass.
b) Pain with resisted wrist flexion (and pronation) with the elbow in full extension
c) Pain with passive terminal wrist extension with the elbow in full extension
- Can also use a modified book test and golfers elbow test

Question 12

Is imaging required for an elbow tendinopathy diagnosis?

Answer 12

No, Diagnostic imaging is often unnecessary for the diagnosis and treatment of elbow tendinopathy in adults and non-elite athletes with classic clinical findings

However, routinely musculoskeletal ultrasound (MSK US) is performed to assess tendon integrity and pathology

Patients with long term pain (3-6 months) or patients who experience worsening of symptoms - plain radiographs to assess for fractures, osteoarthritis, and other bony injuries
Magnetic resonance imaging (MRI) may help clinicians to determine whether surgery is needed

Question 13

What type of diagnosis is performed for elbow tendinopathies?

Answer 13

Elbow tendinopathy is primarily a clinical diagnosis made on the basis of a suggestive history, consistent examination findings, and possibly confirmatory findings using musculoskeletal ultrasound (MSK US).

Question 13

What type of diagnosis is performed for elbow tendinopathies?

Answer 13

Elbow tendinopathy is primarily a clinical diagnosis made on the basis of a suggestive history, consistent examination findings, and possibly confirmatory findings using musculoskeletal ultrasound (MSK US).

Question 14

What are the risk factors for achilles rupture?

Answer 14

Risk factors
a) Male, middle aged
b) Sports activity
c) Chronic inflammatory disease
d) Rheumatoid arthritis
e) Chronic renal failure – impaired collagen synthesis
f) Certain drugs - Corticosteroids & Fluoroquinolone antibiotics – not used in children for this reason

Question 15

What sports are at a high risk of achilles tendinopathy and tendon rupture?

Answer 15

Sports with high risk – sprinters, decathletes, soccer players, track and field jumpers, basketball players, and ice hockey players.

Question 16

What is the anatomy associated with the achilles tendon? Where do most tendon ruptures occur?

Answer 16

Question 17

What are the mechanisms/causes of achilles tendinopathy?

Answer 17

• Acute Achilles tendon pain generally develops when athletes abruptly increase their activity
• Chronic tendon pain (>3 months) may result from sustained stress, poor running mechanics (eg, supination, heel misalignment), or improper footwear.

Underlying - recurrent microtrauma causes degeneration of the achilles tendon - minimal blood supply prevents healing

Damaged tendons become calcified, thickened, inelastic, and fibrotic + neovascularization is observed.

Question 18

When does achilles tendon rupture normally occur?

Answer 18

Rupture occurs when a sudden shear stress (eg. cutting during a basketball game) is applied to an already weakened or degenerative tendon.

Question 19

How do patients with tendinopathy normally present?

Answer 19

Patients with Achilles tendinopathy typically complain of pain or stiffness 2 to 6 cm above the posterior calcaneus – pain is normally described as burning, worse with activity and improves after rest.

Typically a competitive or recreational athletes who have rapidly increased exercise intensity/volume or been training rigorously for an extended period of time

Question 20

How do patients with tendon rupture normally present?

Answer 20

Tendon rupture occurs when sudden forces are exerted upon the Achilles tendon during strenuous physical activities

Patients describe being struck in the back of the ankle, hear a “pop”, experience severe, acute pain, but absence of pain does not rule out rupture.

Question 21

What types of physical examinations on patients with achilles pain?

Answer 21

Examine the area (bruising, etc.) and palpate the achilles tendon for tenderness, thickening, or a defect, recognizing that oedema or a hematoma may mask such a defect.

Presence of crepitus (sounds) with motion suggests tendinopathy

Special tests - Calf squeeze or Thompson test
- Clinician squeezes the gastrocnemius muscle belly while watching for plantarflexion. The absence of plantarflexion when squeezing the gastrocnemius muscle marks a positive test, indicative of rupture

Better than simply asking the patient to plantarflex – action of other muscles may be able to still produce plantarflexion

Question 22

Can a clinical diagnosis be performed for achilles tendinopathy?

Answer 22

Yes, achilles tendinopathy (without rupture) is a clinical diagnosis

Imaging not needed unless you are trying to rule out other conditions – stress fracture or tendon rupture.

Question 23

What tool is used to diagnose partial or complete achilles tendon tears?

Answer 23

Ultrasound imaging is increasingly used to assess tendon appearance and function - accurate tool for diagnosing Achilles tendon tear and distinguishing between partial and complete tears.

Magnetic resonance imaging (MRI) can also be used when tendon rupture is suspected and high-quality diagnostic ultrasound is unavailable.

Question 24

What is the most common joint injured in athletes?

Answer 24

Most common joint injured in athletes – ankle sprains represent 25% of all sports injuries

Question 25

How are ankle sprains treated/managed?

Answer 25

• In general, treatment will consist of RICE (rest, ice, compression, elevation), early mobilization, and rehab.
• Prevention is important - ankle braces, ankle taping, neuromuscular training program, and regular sport-specific warm-up exercises.

Question 26

What is a lateral ankle spain, what does it most commonly involve? What treatments are perscribed?

Answer 26

Most common ankle sprain - lateral inversion sprain that results from landing on an inverted foot with or without plantarflexion.

• Lateral ankle ligaments are the…
  a) Anterior talofibular ligament (ATFL) – most commonly sprained
  b) Calcaneofibular ligament
  c) Posterior talofibular ligament.

Treatment - most commonly treated with RICE initially, then early ambulation, range of motion, progression into strengthening, and then proprioception rehabilitation.

Question 27

What is a medial ankle spain, what does it most commonly involve? What treatments are perscribed?

Answer 27

Medial ankle ligament sprains are rare, account for < 10% of ankle injuries, and are often accompanied with a lateral malleolar fracture or syndesmotic injury (shown below)

Medial ankle ligament is the deltoid ligament and is injured via external rotation or eversion

Ankle sprains are treated similarly to lateral ankle

Question 28

What is a high ankle spain? What ligaments are injured? How are is it treated?

Answer 28

High ankle sprains also known as syndesmotic ankle sprains

Occur through forced external rotation of a dorsiflexed foot most commonly but also occur by forced internal rotation of a fixed plantar flexed foot.

Syndesmotic ligaments injured - connect and stabilize the distal tibia to the distal fibula - includes..
a) anterior tibiofibular ligament
b) posterior tibiofibular ligament
c) transverse tibiofibular ligament
d) Interosseous ligament and membrane

Often these need immobilization with a boot or cast for 1 to 4 weeks to help with healing before beginning rehab - longer healing time

Question 29

What are osteochondral injuries?

Answer 29

Osteochondral injuries are injuries to the articular surface of a joint - also referred to as osteochondral lesions

Injuries range from small undisplaced depressions and cracks in the osteochondral surface to small pieces of articular cartilage and bone that break off of the articular surface and float within the joint.

In osteochondral injuries, osteonecrosis of subchondral bone occurs, resulting in separation of cartilage and subchondral bone from underlying, well-vascularized bone.

Question 30

What are osteochondral injuries normally present? Why are these types of injuries important to keep in mind for ankle injuries?

Answer 30

Typically present with pain in the affected joint and can develop as a result of a specific injury or over several months in highly active athletes.

Cause for pain in up to 25% of ankle injuries and need to be considered when a patient presents with ankle pain.

Question 31

How are osteochondral lesions investigated and treated?

Answer 31

Investigation - OCLs are first evaluated by x-rays and then graded by magnetic resonance imaging (MRI)

Conservative treatment – progress from non-weight bearing, to partial, to full weight bearing + adequate calcium and vitamin D intake to facilitate healing

NSAIDs should be avoided because they can slow bone healing, and OCLs are probably not an inflammatory process

More severe cases and does that have not healed using a conservative treatment – operation is required

Question 32

WHat are the different levels/degrees of osteochondral lesions?

Answer 32

Question 33

What are the common causes of soft tissue injuries?

Answer 33

1. Trauma
2. Sports
3. Overuse
4. Abnormal use/repetitive use
5. Lack of conditioning, lifestyle

Question 34

What is the treatment used for tendinopathies?

Answer 34

• Exercise the tendon as close to its limit as possible - don’t over do
• Strengthening exercises: Tennis elbow
• Analgesia-paracetamol or NSAIDs acutely
• Ice after activity

Question 35

What are the rotator cuff muscles? What role do they play? What the 2 broad groups of injuries?

Answer 35

Rotator cuff comprises four muscles designed to stabilize glenohumeral joint and assist in initiation of movement

Muscles
Anteriorly - Subscapularis
Posteriorly - Supraspinatus, infraspinatus and teres minor

The tendons are vulnerable to injury – these are the injured structures we refer to as ‘rotator cuff tears

Broadly divided into 2 principal groups:
1. Chronic degenerative tears
2. Acute traumatic tears

Question 36

How do rotator cuff tears normally present themselves?

Answer 36

Main symptom – weakness
Secondary – pain
Exclude fracture and neurological cause

Things to keep in mind
- Increase liklihood with age
- Comorbidities – diabetes
- History of Subacromial impingement

Question 37

What physical tests should be performed to examine each of the rotator cuff muscles?

Answer 37

Supraspinatus – resisted abduction with thumbs down to defunction deltoid

Infraspinatus and teres minor – resisted external rotation

Subscapularis – Resisted internal rotation

Question 38

What investigations can be performed for a rotator cuff injury?

Answer 38

Ultrasound scan/MRI – Confirms cuff tear and dimensions

X-ray – shoulder trauma series to exclude fracture or dislocation

Question 39

How are rotator cuff injuries managed?

Answer 39

Question 40

What is the management for an achilles tendon rupture?

Answer 40

Question 41

What are the Ottowa rules for deciding to X-ray an ankle?

Answer 41

Ottowa rules

Ankle X-ray: Pain in malleolar area AND any of the following
1. Unable to weight bear
2. Bony tenderness at point A (posterior edge/tip of lateral malleolus - fibula)
3. Bony tenderness at point B (posterior edge/tip of lateral malleolus - tibia)

Question 42

Overarching management of ankle sprains?

Answer 42

1. Analgesia
2. Rest including a controlled ankle motion walking boot
3. Ice
4. Compression
5. Elevation
6. Physical rehabilitation - Early ankle motion - important! - therabands, strengthening and improve proprioception