Sports Flashcards
The highest risk to tensile failure of the rotator cuff during throwing is during….
deceleration due to the eccentric contraction of the cuff to decelerate the arm.
Second impact syndrome occurs due to….
disruption of cerebral autoregulation leading to cerebral vascular congestion, edema and death.
The Immediate Post-Concussion and Cognitive Testing Battery (ImPACT) evaluates an athletes…
attention, memory and processing speed.
A player with a stinger can return to play when…
they are asymptomatic with painless neck ROM.
The posterior approach to the shoulder (Judet) utilizes the plane between…
the infraspinatus (suprascapular nerve) and the teres minor (axillary nerve).
Athletic pubalgia (sports hernia) is due to…
repetitive thigh extension and abduction leading to strain of the adductors (specifically adductor longus).
Osteitis pubis
repetitive trauma leads to pain and osteolysis/erosion oft the pubic symphysis.
Piriformis syndrome
compression of the sciatic nerve (usually runs anterior to the piriformis and posterior to the SERs)
Treatment for a quadriceps contusion
immobilization with knee flexion for first 24 hours, then PT
Effect of steroids on cholesterol levels
increases LDL and decreases HDL
An os acromiale is usually between…
meso and meta acromion.
Calcific tendonitis is deposition of…
calcium hydroxyapaptite usually in the supraspinatus tendon. Associated with diabetes.
The initial tear location of a degenerative RC tear is…
15 mm posterior to the biceps tendon near the supraspinatus/infraspinatus junction.
RC Tears that should be converted to full thickness and repaired:
- bursal sided RCT > 3 mm
2. articular sided RCT > 6 mm
What are the landmarks for upper border subscapularis repair?
SGHL and CHL
Treatment of irreparable subscapularis tear
pectoralis major tendon transfer (puts the musculocutaneous nerve at risk)
The supraspinatus tendon medial to lateral width is normally…
12.1-12.7 mm.
The greatest risk factor for nonhealing after RCR is…
age > 65 years.
Treatment of irreparable supraspinatus/infraspinatus tear
Young, laborer: latissimus dorsi transfer (radial nerve at risk during harvest)
Elder: rTSA
An interscalene block gives risk for…
tension PTX (distended neck veins, distant heart sounds, hypotension). Treat with emergent needle decompression in 2nd intercostal space.
What nerve is at risk with inferior placement of the posterior shoulder portal?
axillary nerve
Anterosuperior humeral head migration occurs when…
both cuff and CA ligament are deficient.
SLAP tear is associated with…
GIRD and spinoglenoid cyst.
What nerve is at risk with arthroscopic repair of a SLAP tear?
suprascapular nerve (especially when there is medial perforation of the glenoid neck).
During a SLAP repair, if there is fraying of biceps or instability then…
perform tenodesis.
Maximum shoulder ABD and ER causes significant tension on…
the posteroinferior capsule which can lead to mineralization/exostosis of the posteroinferior glenoid (traction spur or Bennett lesion).
What direction does the humeral head shift during late cocking/early acceleration in a GIRD shoulder?
posterosuperior
The long head of the biceps predominantly attaches on the…
posterior aspect of the glenoid.
What movement should be avoided after biceps tenodesis?
seated active forearm supination with elbow flexed to 90
Little Leaguer’s shoulder
- proximal humerus SHI physeal injury (thru the hypertrophic zone)
- stop pitching and start PT (progressive throwing program eventually)
Adhesive capsulitis is….
contracture of the rotator interval and CHL –> decreased intracapsular volume and loss of the axillary recess
Surgical releases for adhesive capsulitis
Release of rotator interval (anterior superior capsule) will increase ER w/ arm by side (which is the most limited ROM typically).
Release of the posterior capsule will increase IR.
What does histology of adhesive capsulitis show?
fibroblastic proliferation
Initial workup of adhesive capsulitis should inlcude…
HbA1c and TSH levels.
associated with DM (poor prognosis) and hypothyroidism
Medial scpaular winging
long thoracic nerve palsy (weak serratus anterior)
Lateral scapular winging
spinal accessory nerve palsy (weak trapezius)
Distal clavicle osteolysis is a..
stress reaction seen from repetitive trauma (hyperemic response, localized bone resorption, cyst formation).
Typically seen in weightlifters and laborers.
Treatment of distal clavicle osteolysis
distal clavicle resection
**refractory to non-operative treatment
Anatomy of the suprascapular notch
suprascapular artery runs above the suprascapular ligament, suprascapular nerve runs below
Pec major rupture often involves…
a tendinous avulsion off bone during eccentric contraction (downward deceleration during bench press).
The pec major inserts…
on the humeral shaft lateral to the bicipital groove (adduction and IR of arm). Innervated by medial and lateral pectoral nerves.
What position should the arm be in for MRI of distal biceps tendon rupture?
Elbow flexed, shoulder abducted, and forearm supinated
Within the antecubital fossa, the bicep tendon travels…
lateral to the median nerve and posterior to the recurrent radial artery.
A partial distal biceps tendon tear typically occurs on…
the radial side of the bicipital tuberosity. If it fails non-op tx, then complete the tear and repair it.
Non-operative tx of a distal biceps tendon tear will result in…
30% loss of elbow flexion strength and 40% loss of supination strength.
Single incision distal biceps repair risk
LABCN injury (branch of musculocutaneous) and can also injure the raidal nerve/PIN/superficial sensory radial nerve
Dual incision distal biceps repair risk
HO
**however, more anatomic placement of the repair
Little Leaguer’s Elbow
medial elbow pain 2/2 UCL injury/medial epicondyle stress fx/strain of flexor-pronator muscle group
X-rays of Little Leaguer’s Elbow will show…
widening of the medial epicondylar apophysis
A little league pitcher can also develop…
an olecranon stress fx which will demonstrate posteromedial elbow pain and widening of the olecranon apophysis. Treat non-op but if fails, then ORIF w/ compression screw.
In pitcher’s elbow (valgus extension overload), there will be…
osteophytes developing in the posteromedial tip of the olecranon.
If pitcher’s elbow non-op managment fails, then…
treat with arthroscopic excision. The most common reason for repeat surgery is valgus instability (avoid overresection of the olecranon).
The anterior oblique bundle of the MUCL is the…
primary stabilizer to valgus stress (moving stress test).
The anterior band of the AOL of the MUCL is…
tight in extension and shows isometric strain through elbow ROM.
The posterior oblique band of the AOL of the MUCL is…
tight in flexion.
The posterior oblique bundle of the MUCL demonstrates the greatest change in…
tension from flexion (tight) to extension.
The UCL is typically reconstructed with…
the palmaris longus autograft.
The most common complication of UCL reconstruction is…
ulnar neuritis.
The docking technique of UCL reconstruction provides…
higher rate of return to play and lower complication rate compared to the Jobe and modified Jobe techniques.
Posterolateral rotatory instability of the elbow is…
LUCL injury from elbow dislocation or iatrogenic injury during debridement of lateral epicondylitis.
Demonstrates instability with chair rise.
During lateral elbow dissection, debridement should be kept…
anterior to the equator of the capitellum/radial head to avoid injury to the LUCL.
Lateral pivot shift
forearm supination and valgus stress while bringing the elbow from extension to flexion –> extension dislocates and flexion reduces the radiocapitellar joint
LUCL is typically reconstructed with…
palmaris longus autograft.
Lateral epicondylitis
tendinitis at the origin of ECRB which inserts on the base of the 3rd MC.
Steroid injection in lateral epicondylitis does…
not affect outcomes.
Histology of lateral epicondylitis
angiofibroblastic hyperplasia/proliferation
Medial epicondylitis
tendinitis of the flexor pronator mass.
Most common coexisting pathology of medial epicondylitis is…
ulnar neuropathy.
Internal snapping hip (coxa saltans)
iliopsoas tendon sliding over the iliopectineal eminence or femoral head.
Provocative test: reproduces popping when the hip is moved from FABER to neutral position
Treatment of internal snapping hip
cortisone injection, psoas tendon release
During hip arthroscopy, the zona orbicularis is the landmark for…
the iliopsoas tendon.
External snapping hip
IT band sliding over the GT
+Ober test (limited hip adduction w/ hip extended)
Labral tear w/ FAI is usually…
anterosuperior.
Anterior impingement in FAI can result in…
contra-coup chondral injury on the posteroinferior acetabulum.
CAM FAI is typically seen in…
athletic male, femoral neck retroversion, alpha angle > 42
Pincer FAI is typically seen in…
middle-aged females, acetabular retroversion and crossover sign
If open surgical hip dislocation is required for FAI, perform a…
trochanteric flip osteotomy to protect the MCFA.
After open FAI tx, adolescent athletes can return to sport at…
7 months.
In hip arthroscopy, the most common traction neuropraxia is…
pudendal nerve.
Hip scope anterolateral portal danger
superior gluteal nerve
Hip scope posterolateral portal danger
sciatic nerve, especially if hip is ER when establishing the portal
Hip scope anterior portal danger
LFCN, femoral NV bundle
Hamstring tear usually occurs at…
the myotendinous junction during sprinting (eccentric contraction when hip is flexed and knee extended).
Which cells are involved in muscle regeneration after injury?
satellite cells
During an acute muscle injury, which cells are first to appear?
neutrophils
In muscle injury, TGF-beta stimulates….
myofibroblast proliferation –> increased fibrosis.
Which meniscus is more commonly discoid?
lateral
20% bilateral
X-rays of discoid meniscus show…
squaring of the lateral femoral condyle
Why is medial meniscus more prone to injury than lateral?
it is less mobile (especially posterior horn).
**exception is lateral meniscus injury more common with ACL tear
What artery supplies the periphery of the menisci?
medial and lateral inferior genicular arteries
A smaller meniscal rim width (distance from the tear to the periphery) is associated with…
better healing potential due to better blood supply.
What is the most sensitive exam finding for meniscus injury?
joint line tenderness
A baker cyst occurs between…
the semimembranosus and medial head of the gastroc.
The strongest predictor of outcome after meniscectomy is…
the degree of OA.
The gold standard for meniscus surgery is…
inside-out technique with vertical mattress sutures.
Approach for lateral meniscus injury
between posterolateral joint capsule (posterior to LCL) and lateral head of gastroc
Approach to medial meniscus tear
between posteromedial joint capsule (posterior to MCL) and medial head of gastroc
What is an absolute contraindication to meniscal transplantation?
inflammatory arthritis
ACL receives blood supply from the middle genicular artery which arises from…
the popliteal artery.
What polymorphism is associated with lower risk for ACL rupture in women?
COL5A1
Bone bruises on MRI in ACL tear is a predictor of…
motion deficit following ACL reconstruction.
Where are bone bruises in ACL tear?
middle 1/3 of lateral femoral condyle and posterior 1/3 of lateral tibial plateau
Which autograft has the most tensile stiffness?
BTB
With hamstring graft, what is the smallest diameter that can minimize risk for rerupture?
8.5 mm
The bifurcate ridge separates…
the femoral attachment sites of anteromedial and posterolateral bundles.
Pivot shift test
when knee is extended and IR/valgus force is applied, as knee is flexed, lateral plateau slides posteriorly and reduces, producing a clunk
Drilling the femoral tunnel via the anteromedial portal allows…
more anatomic graft placement compared to transtibial drilling.
Resident’s ridge is known as…
the lateral intercondylar ridge
The most common error in ACL tunnel placement is…
anterior femoral tunnel placement which leads to loss of knee flexion as the graft will be tight in flexion
Vertical femoral tunnel placement leads to…
rotational instability (failure to reconstruct the posterolateral bundle) and impingement agains teh PCL.
The tibial tunnel for ACL should be placed…
9 mm posterior to the posterior aspect of the intermeniscal ligament.
An anteriorly placed tibial tunnel will lead to…
a graft that is tight in flexion and notch impingement with extension.
The greatest risk factor for recurrent ACL rupture after reconstruction is…
patient age.
What level of graft-screw divergence decreases pullout strength?
> 30 degrees and this leads to fixation failure.
What is the most common cause of septic arthritis following ACL reconstruction?
S epidermidis
Physeal sparing techniques in pediatric ACL reconstruction prevent
- tibial recurvatum (due to tibial tubercle apophyseal arrest)
- prevent LLD or angular deformity (distal femoral physeal arrest)
PCL injury is usually due to…
direct blow (dashboard injury) or a fall onto a flexed knee with foot in plantarflexion
chronic PCL deficiency causes arthritis in the…
medial and patellofemoral knee compartments.
Blood supply to PCL
middle geniculate artery
PT for PCL injury should focus on…
quad strengthening to counter posterior translation of the tibia.
(and avoid immediate hamstring exercises if you do reconstruct)
For PCL reconstruction, the graft should be tensioned at…
90 degrees of knee flexion (native AL bundle is tight in flexion).
When performing HTO to correct varus malalignment in a PCL deficient knee, increasing tibial slope will…
decrease posterior tibial subluxation leading to greater stability.
In ACL deficient knee, decreasing the tibial slope will…
shift the tibia posteriorly –> less anterior translation of the tibia and more stability.
MCL injury is usually a…
ligamentous avulsion at the femoral insertion.
Do proximal or distal MCL tears heal better?
proximal heal better
Relative to the popliteus insertion, the femoral origin of the LCL is…
posterior and proximal.
(POP is DAD - popliteus is distal, anterior and deep).
Relative to the popliteofibular ligament, the LCL inserts….
anteriorly on the fibular head.
If osgood-schlatter fails non-op management, then tx w/
ossicle resection and tibial tubercleplasty.
Sinding-Larsen-Johansson syndrome
traction apophysitis at the inferior pole of the patella
Most common location for knee OCD
posterolateral aspect of medial femoral condyle
Microfracture acts to…
perforate subchondral bone to stimulate mesenchymal stem cells to fill the defect with fibrocartilage (type I collagen)
For an OCD, < 2 cm by 2 cm defect, treat with…
microfracture or osteochondral autograft
For an OCD, > 2x2 cm, treat with…
osteochondral allograft transplantation (OAT) or autologous chonrocyte implantation (ACI)
in autologous osteochondral mosaicplasty, bone graft will incorporate…
into subchondral bone and cartilage will remain viable.
Treatment of patellofemoral OCD
ACI w/ anteromedial tibial tubercle transfer provides better results than ACI alone
Most common injury of the MPFL is…
soft tissue avulsion off the femoral attachment.
Most common osteochondral injury during a traumatic lateral patellar dislocation is…
medial patellar facet.
MPFL should be reconstructed in…
30 degrees of knee flexion.
Lateral patellar instability normally causes…
increased contact pressure over the inferior and lateral aspects of the patella.
Anteromedialization of the TT will increase contact over the superior and medial aspects of the patella.
Suture anchor fixation of quad tendon rupture results in…
smaller gap formation and higher ultimate failure strength than transosseous suture fixation.
Tibial stress syndrome (shin splints)
traction periostitis of the posterior tibialis and soleus –> medial stress syndrome
(medial tibial stress syndrome is more common)
traction periostitis of tib ant –> anterior stress syndomre
In tibial stress syndrome, pain improves with…
training running (unlike stress fx).
An anterior sided tibial stress fx is…
more difficult to heal than posterior side.
