Sports Medicine Flashcards
Nonortho conditions of sports medicine?
- infectious disease: derm (MRSA)
- diabetes
- exercised induced issues
- concussions
- preparticipation assessment
- female athlete: title IX, female triad (eating disorders, amenorrhea, osteoporosis)
- psych:
athlete, parent, coaches
Common sports related shoulder injuries?
- rotator cuff disease
- degeneration
- instability
- biceps and SLAP lesions
Common sports related elbow injuries?
- medial pain issues
- lateral pain issues
Common sports related knee, foot, and ankle injuries?
knee:
- ACL
- meniscal injuries
- articular cartilage
- anterior knee pain
foot and ankle:
- sprains
What pts are at risk for rotator cuff injury?
- trauma
- repetitive overuse
- degenerative tendon: older athletes (normal aging + sports further puts stress on tendon complex)
Non-op tx of rotator cuff injury?
Reduce inflammation:
- time
- activity shutdown
- NSAIDs
- subacromial injection
- modalities
- PT: ROM and strength
Surgical options for rotator cuff tear?
- open repair
- mini-open repair
- arthroscopic (easier rehab for pt but still same time frame)
- total shoulder repair: 3% failure rate, predictable pain relief immediately after surgery, excellent fxn
Post op course for rotator cuff surgery?
- sling for 6 wks
- rehab for 3 mos
- golf 4-5 mos
- tennis 6 mos
- swimming 7-8 mos
- full recovery 1 yr
Tx for shoulder arthritis?
early/moderate:
- activity modification
- NSAIDs
- steroid injections
- PT
- arthroscopy
severe:
- shoulder replacement
Tx of 1st shoulder dislocation?
Anterior or Posterior
- reduction: XR (have to look for tear- bankart lesion)
- immediate: ER brace
- surgical
- risk of another dislocation if active: 85%
Pros and cons of open instability tx?
pros:
- higher success rate
- better in ligamentously lax
- glenoid reconstruction possible
cons:
- risks of over tightening
- painful post-op
Tx for biceps degeneration/tendonitis?
Assoc w/ rotator cuff tear?
- if isolated tx w/ non-op management, if this then fails tx surgically
- if also have assoc rotator cuff tear (this is common) - surgical tx
What pts w/ bicep tears need surgery?
- if they have hard time actively supinating and if their livelihood is dependent on ROM of biceps (supination)
- laborers
- young throwers
Physical exam findings of biceps tear?
- speeds, yergason’s
- often + Hawkins/neer impingement
Subscap tests?
- stomach compression (upper portion)
- lift-off (lower portion)
- bear hug
Dx imaging for biceps tear?
- MRI:
moderate accuracy for biceps disease, gadolinium recommended: up to 97% assoc w/ RCT - US
Non-op management for biceps tear?
- spontaneous rupture: tx non-op
- non-op management:
Rest
NSAIDs
PT: rotator cuff strengthening
injections: intra-articular
Surgical indications for tenotomy or tenodesis?
- subluxation or dislocation of biceps
- greater than 25% tear
- sig inflammation, atrophy, hyprertrophy
- routine during TSR and HHR (esp fx/stiffness)
- irreparable rotator cuff tear
Tenotomy vs tenodesis?
surgeon/pt preference:
- tenotomy:
elderly, cosmesis less of concern, easier rehab, revision
- tenodesis:
younger than 50, cosmoses/strength is a concern (laborer)
Typical presentation of pt w/ SLAP tear?
- usually thrower (ABER force)
- CC: instability (internal impingement)
Tests for SLAP tear?
- Obrien’s test: 100% SENS, 98% SPEC
- Crank test
- have to diff b/t AC jt injury and SLAP tear (cross body to eval AC)
Non-op management of Slap lesion?
- Rest
- NSAIDs
- PTx 3 months:
rotator cuff strengthening (instability)
scapula strengthening
posterior capsular stretching (internal impingement) - throwing program
indications for SLAP repair?
- young pt (under 40)
- mechanical sxs
- assoc:
- instability - (drive through sign), esp if glenohumeral ligaments attached
- internal impingement
- acute rotator cuff tear
CIs to SLAP repair?
- elderly (consider tenotomy)
- frozen shoulder
- anatomic variant: no exposed cartilage, doesn’t match sxs
- chronic rotator cuff tear
DDx of medial elbow pain?
- medial epicondylitis
- ulnar neuropathy
- flexor pronator strain
- pronator syndrome: entrapment of AIN (anterior interosseous nerve (branch of median nerve))
- ulnar or medial collateral ligament
- olecranon stress fx
DDx for lateral elbow pain?
- lateral epicondylitis
- radial tunnel syndrome: entrapment of PIN
- lateral ulnar collateral ligament
- Capitellar OCD
Etiology of lateral epicondyltis (aka tennis elbow)?
- overuse injury involving eccentric overload at origin of common extensor tendons
- repetitive pronation/supination w/ elbow extended
- microtear of ECRB
- non-op tx 95% successful
Presentation and Tx of lateral epicondylitis?
presentation:
- pain w/ resisted wrist extension, gripping, pain at ECRB insertion
- pain w/ resisted wrist extension w/ elbow extended
tx:
- ice, NSAIDs, rest, US
- larger raquet grip
- injections: some benefit from corticosteroid injection, no indication for effectiveness f PRP
- rarely reqrs release and debridement of ECRB
Hx of elbow MCL tear?
- 37 y/o RHD pitcher
- no previous elbow probs
- felt pop/pain w/ fastball
- couldn’t continue to pitch
PE findings of MCL tear?
- pain: medial elbow at AMCL insertion
- location: milking tests, valgus stress test, jobe reconstruction
- mild pain, weakness:
wrist flexion and forearm pronation
What bundle is affected in a medial collateral ligament tear?
- Anterior bundle
Management for medial collateral ligament tear if no indications for surgery?
rehab: - std x 6 wks: 2 wks acute inflammation: rest, ice, modalities (phon, ionto, contrast pools), then active/passive c/ modalities - throwing progam x 3mos short toss - long toss - to the mound if fails - then repeat program
Surgical indications for medial collateral ligament repair?
- no probs w/ ADL
- no probs w/ warm up
- pain w/ throwing 70-100% effort
- pain/tingling ulnar distribution
Classic presentation of ACL injury?
- sudden deceleration
- twist
- pivot
- cut
- clipping/pile-up
- backward fall skiing
What is involved in surgical discussion w/ pt?
- know your pt:
lifestyle: activity or sedentary, activities, desires for the future - be sure pt understands surgical and non-surgical tx
- rehab is tough and long: 4-6 months
Only way to restore ACL tendon?
- doesn/t heal, doesn’t do well w/ primary repair
- restore only through reconstruction:
probs due to synovial enviro, unlike MCL which is outside jt and can heal w/o surgery
Surgical options for ACL (component used)?
- patella tendon
- hamstring
- quads tendon
- allograft tendon:
patella, achilles, tibial - if under 22: risk of re-tear w/ cadaver tissue extremely high compared to allograft
DDx of anterior knee pain?
- PFS: cartilage changes, maltracking
- quad or patellar tendon pain
- Osgood Schlatter’s disease
Is anteior knee pain common? How can you track problem? Tx?
- very common: esp in females
- track problem: Q angle
- conservative tx:
rehab, brace - surgery
WHat is Osgood Schlatters?
- tibial tubercle Apophysitis
- more common in males: boys 12-15, girls 8-12
- stress from extensor mechanism
- self-limiting, dependent on growth plate closure (weakest part of the bone)
Presentation of Osgood Schlatters?
- pain at anterior aspect, worse w/ kneeling
- tender over enlarged tubercle
- worse w/ resisted extension
Tx of Osgood Schlatters?
- NSAIDs, rest, ice, activity modification
- quad + hamstring strenghening
- 90% resovle: time limiting
- for severe sxs: cast
- rarely reqrs ossicle excision: skeletally mature w/ sxs
Foot and ankle exam?
- examine pt while sitting and standing
- assess ROM of ankle, hindfoot, and forefoot
- midfoot is examined w/ pronation and abduction stresses
- neurovascular exam impt in all pts
- key to any exam:
where does it hurt?
Discrete palpation
manipulation
MC injuries in sports?
- ankle ligament injuries
- lateral ankle ligaments are MC injured structures (inversion) - anterior talofibular and calcaneofibular ligaments
- account for 54% of all VB injuries and 45% of bball injuries
DDx of twisting injuries of ankle?
- lateral ligament structures
- syndesmosis
- articular cartilage of talus (osteochondral dessicans)
- peroneal tendons
- base of 5th metatarsal
- subtalar jt
- fx about ankle (growth plate injuries)
- lateral and anterior process of talus fx
- superficial peroneal or sural nerves
- calcaneal-cuboid and lisfranc jts
Distal tibia, fibula and talus form what jt?
- mortise jt
- held together by anterior, posterior tibiofibular ligament and syndesmosis
Primary ligamentous support?
lateral ligament complex:
- ATFL (anterior talofibular ligament)
- CFL (calcaneofibular ligament)
- PTFL (posterior talofibular ligament)
medial or deltoid ligament complex
Fxn of peroneal tendons?
- laterally provide resistance to inversion injuries
- nerves of propioception in ankle jt and ligaments signal these to contract to protect the jt from plantar flexion and inversion
Fxn of posterior tibialis muscle?
- antagonist to peroneals
- provides resistance to eversion stresses
Why are medial ligaments less likely to be injured?
- b/c of the more of prominent bony barriers to eversion
- result from ankle external rotation and eversion
MOI of lateral collateral ligaments?
- sprains tend to occur when jt is in position that provides little bony stability, in the ankle this is plantar flexion and inversion
- talus is narrower posteriorly than anteriorly and in dorsiflexion the wider talus engages the mortise w/ a tighter fit
- inversion is less stable b/c of the lengths of medial and lateral malleoli differ: lateral extends further distally and blocks lateral talar movement
in this position ligament ijnjuries will occur - ATFL assumes a vertical orientation when the ankle is plantar flexed and inverted and is at max tension in this position: the primary lateral stabilizer of the ankle
- the CFL is under most tension in dorsiflexion but if the ATFL is injured or fails it is then subjected to inversion stresses, if both ATFL and CFL fail - PTFL may be injured
- predictable pattern of injury:
difficult to injure CFL or PTFL w/o 1st injuring the ATFL
RFs for inversion injuries?
- biomechanical factors may cause excessive forces to lateral ankle and place the ankle at risk for inversion injuries:
- tight achilles: eval gastrosoleus complex
- varus hindfoot
- limited subtalar motion:
tarsal coalitions, peroneal spastic flatfeet
PE for lateral ankle injuries?
- inspection: ID swelling, ecchymosis, deformity - palpation: must palpate bony structures - *tenderness over bone or growth plates bring high suspicion for fx *prox fibula: maissnove * base of 5th metatarsal * lateral talar process * ligaments: ATFL, CFL, PTFL, anterior tibiofibular ligament, deltoid - syndesmosis or interosseous injuries * tendons: peroneal and achilles
Tests for ankle instability?
ligament testing:
- anterior drawer test:
specific to the ATFL: ankle in neutral position w/ heel and tibia stabilized and forward stress placed on heel
- talar tilt test: ankle in neutral to place stress on CFL - apply varus stress. Must block subtalar motion
When is XR warranted for lateral ankle injuries? What views are needed? What are you looking for?
- when palpable pain is present on bony areas
- not all acute ankle injuries need XRs
- AP, lateral, and mortise views
- look for fx, displacement of mortise, widening of growth plates (fibular), loose bodies or OCD
- MRI has a valuable role in eval of chronic ankle pain, but has no role in acute situation
Other dx tests for lateral ankle injuries?
- radiographic stress tests:
no role in acute w/u
compare to opp ankle - radiographic anterior drawer:
ATFL test, anterior displacement greater than 4 mm is felt to be abnormal - radiographic talar tilt: diff b/t 6 mm is felt to be abnormal
Tx of lateral ankle sprains?
- effective tx is based on accurate dx
- grade I and II ankle sprains should be tx conservatively:
early wt bearing and ROM show less pain, less atrophy and earlier return to activities - grade III more controversial:
diff options: early mobilization, cast immobilization, primary surgery:
Grade III: progress through stages slower, during phase I they reqr brace w/ hindfoot lock or short leg dorsiflexion walking cast: if casted not to be used for more than 7-10 days
Tx of chronic ankle instability?
- sig % of athletes will develop chronic instability
- documented by PE and stress xrays
- reconstruction may be indicated after failure of rehab program of propioception, muscle strengthening, and achilles stretching
What is mechanical and fxnl instability of the ankle?
- mechanical: increased ankle mobility - more than 10 mm of anterior translation or side-side difference of 3 mm
talar tilt: greater than 9 mm or side-side greater than 3 mm - fxnl:
feeling of ankle giving way - often result of inadequate rehab
Ligaments involved in syndesmotic injuries?
high ankle sprains - 3 ligaments unite distal tib-fib: anterior tibfib posterior tibfib iterosseous - 11% of ankle sprains - disruptions occur w/ or w/o fibular fx - MOI is external rotational and dorsiflexion - often have longer rehab time w/ more longterm disability than lateral ankle sprains
Dx of syndesmotic injuries?
- tender over anterior syndesmosis
- common to have deltoid tenderness
- maisonneuve fx will have tenderness at prox fibula plus syndesmosis
- compression squeeze test:
squeeze at mid-calf will cause pain at ant. syndesmosis - external rotation test: done q/ knee at 90 degrees
Tx of syndesmotic injuries?
- partial injury: tx w/ boot or walking cast for 2-4 wks followed by rehab (return to play usually 2x as long as for severe ankle sprain (4.5-6 wks)
- if widening noted on plain or stress view:
surgical repair is indicated -
screw placed w/ ankle in max dorsiflexion, non wt being cast/wt bearing immobilization, screw removed at 10-12 wks, may develop heterotopic ossificaiton w/ pain on push-off
Assessment of persistently painful sprained ankles?
- as many as 20-40% are reported to have residual pain that limits their activities after grade III injury
- complaints may be vague pain, feeling of giving way, problems walking on uneven ground, swelling, stiffness, locking
- limited dorsiflexion is often involved and can be from achilles or more proximal
DDx for persistently painful sprained ankles?
- incomplete rehab**
- intra-articular issues: OCD, loose bodies
- chronic instability
- subtalar sprains
- syndesmotic sprains
- impingement issues
- sinus tarsi syndrome
- chronic tendon disorders
- stress fx
- undetected epiphyseal injuries
- tumors
What are stress fx? MC occur?
- fatigue induced fx of bone caused by repeated stress over time: result of accum trauma from sub-max loading
- most often occur in wt bearing bones:
tibia, metatarsals, navicular, femoral neck, may occur assoc w/ growth plates
Etiology of stress fx?
- bones constantly remodeling, w/ overus and stress the capacity to do so is exhausted and weak area develops:
osteoblasts overwhelmed, bone and muscles serve as shock absorbers to stress: w/ muscle fatigue the bone may be taxed - female athlete triad: commonly assoc w/ recurrent stress fx:
amenorrhea (lead to demineralization and stress fx), disordered eating (insuff caloric intake - cause amenorrhea), leads to osteoporosis
Presentation of stress fx?
- pain w/ wt bearing that increases w/ exercise or activity: usually resides w/ rest
- may have area of localized tenderness on or near bone and generalized swelling
Dx of stress fx?
- xrays: acutely may not show evidence - may take 10-14 days b/f bone remodeling is present
- MRI or bone scan is more sensitive
Tx of stress fx?
- rest combined w/ unloading of stress area to time when pain isn’t present: walking boots, crutches
- gradual return to activities that caused issues - 10% increase/wk
- for fx that don’t respond or have sig risk to not heal - fixation
Prevention of stress fx?
- allow for gradual ramp up of loading activities: allow bone to adapt to increased stresses
- strengthening of muscles: calf and shin
- replace shoes q 300-700 miles
- increase Ca and Vit D
- address issues assoc w/ female triad
Presentation of tibial stress fx? Tx?
- pain directly over fx
- tx:
activity restriction w/ protected wt bearing
rarely IM nail ( only if allowed to develop and not able to heal)
Diff types of femoral neck stress fx? Study of choice?
- compression side: inferior medial neck
- tension side: superior lateral (need surgical tx - worry about AVN)
- MRI study of choice
