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Ortho > Sports Medicine > Flashcards

Sports Medicine Flashcards

1
Q

Nonortho conditions of sports medicine?

A
  • 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
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2
Q

Common sports related shoulder injuries?

A
  • rotator cuff disease
  • degeneration
  • instability
  • biceps and SLAP lesions
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3
Q

Common sports related elbow injuries?

A
  • medial pain issues

- lateral pain issues

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4
Q

Common sports related knee, foot, and ankle injuries?

A

knee:

  • ACL
  • meniscal injuries
  • articular cartilage
  • anterior knee pain

foot and ankle:
- sprains

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5
Q

What pts are at risk for rotator cuff injury?

A
  • trauma
  • repetitive overuse
  • degenerative tendon: older athletes (normal aging + sports further puts stress on tendon complex)
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6
Q

Non-op tx of rotator cuff injury?

A

Reduce inflammation:

  • time
  • activity shutdown
  • NSAIDs
  • subacromial injection
  • modalities
  • PT: ROM and strength
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7
Q

Surgical options for rotator cuff tear?

A
  • 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
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8
Q

Post op course for rotator cuff surgery?

A
  • sling for 6 wks
  • rehab for 3 mos
  • golf 4-5 mos
  • tennis 6 mos
  • swimming 7-8 mos
  • full recovery 1 yr
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9
Q

Tx for shoulder arthritis?

A

early/moderate:

  • activity modification
  • NSAIDs
  • steroid injections
  • PT
  • arthroscopy

severe:
- shoulder replacement

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10
Q

Tx of 1st shoulder dislocation?

A

Anterior or Posterior

  • reduction: XR (have to look for tear- bankart lesion)
  • immediate: ER brace
  • surgical
  • risk of another dislocation if active: 85%
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11
Q

Pros and cons of open instability tx?

A

pros:

  • higher success rate
  • better in ligamentously lax
  • glenoid reconstruction possible

cons:

  • risks of over tightening
  • painful post-op
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12
Q

Tx for biceps degeneration/tendonitis?

Assoc w/ rotator cuff tear?

A
  • 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
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13
Q

What pts w/ bicep tears need surgery?

A
  • if they have hard time actively supinating and if their livelihood is dependent on ROM of biceps (supination)
  • laborers
  • young throwers
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14
Q

Physical exam findings of biceps tear?

A
    • speeds, yergason’s

- often + Hawkins/neer impingement

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15
Q

Subscap tests?

A
  • stomach compression (upper portion)
  • lift-off (lower portion)
  • bear hug
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16
Q

Dx imaging for biceps tear?

A
  • MRI:
    moderate accuracy for biceps disease, gadolinium recommended: up to 97% assoc w/ RCT
  • US
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17
Q

Non-op management for biceps tear?

A
  • spontaneous rupture: tx non-op
  • non-op management:
    Rest
    NSAIDs
    PT: rotator cuff strengthening
    injections: intra-articular
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18
Q

Surgical indications for tenotomy or tenodesis?

A
  • 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
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19
Q

Tenotomy vs tenodesis?

A

surgeon/pt preference:
- tenotomy:
elderly, cosmesis less of concern, easier rehab, revision
- tenodesis:
younger than 50, cosmoses/strength is a concern (laborer)

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20
Q

Typical presentation of pt w/ SLAP tear?

A
  • usually thrower (ABER force)

- CC: instability (internal impingement)

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21
Q

Tests for SLAP tear?

A
  • 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)
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22
Q

Non-op management of Slap lesion?

A
  • Rest
  • NSAIDs
  • PTx 3 months:
    rotator cuff strengthening (instability)
    scapula strengthening
    posterior capsular stretching (internal impingement)
  • throwing program
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23
Q

indications for SLAP repair?

A
  • young pt (under 40)
  • mechanical sxs
  • assoc:
  • instability - (drive through sign), esp if glenohumeral ligaments attached
  • internal impingement
  • acute rotator cuff tear
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24
Q

CIs to SLAP repair?

A
  • elderly (consider tenotomy)
  • frozen shoulder
  • anatomic variant: no exposed cartilage, doesn’t match sxs
  • chronic rotator cuff tear
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25
Q

DDx of medial elbow pain?

A
  • 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
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26
Q

DDx for lateral elbow pain?

A
  • lateral epicondylitis
  • radial tunnel syndrome: entrapment of PIN
  • lateral ulnar collateral ligament
  • Capitellar OCD
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27
Q

Etiology of lateral epicondyltis (aka tennis elbow)?

A
  • 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
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28
Q

Presentation and Tx of lateral epicondylitis?

A

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
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29
Q

Hx of elbow MCL tear?

A
  • 37 y/o RHD pitcher
  • no previous elbow probs
  • felt pop/pain w/ fastball
  • couldn’t continue to pitch
30
Q

PE findings of MCL tear?

A
  • pain: medial elbow at AMCL insertion
  • location: milking tests, valgus stress test, jobe reconstruction
  • mild pain, weakness:
    wrist flexion and forearm pronation
31
Q

What bundle is affected in a medial collateral ligament tear?

A
  • Anterior bundle
32
Q

Management for medial collateral ligament tear if no indications for surgery?

A 
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
33
Q

Surgical indications for medial collateral ligament repair?

A
  • no probs w/ ADL
  • no probs w/ warm up
  • pain w/ throwing 70-100% effort
  • pain/tingling ulnar distribution
34
Q

Classic presentation of ACL injury?

A
  • sudden deceleration
  • twist
  • pivot
  • cut
  • clipping/pile-up
  • backward fall skiing
35
Q

What is involved in surgical discussion w/ pt?

A
  • 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
36
Q

Only way to restore ACL tendon?

A
  • 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
37
Q

Surgical options for ACL (component used)?

A
  • 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
38
Q

DDx of anterior knee pain?

A
  • PFS: cartilage changes, maltracking
  • quad or patellar tendon pain
  • Osgood Schlatter’s disease
39
Q

Is anteior knee pain common? How can you track problem? Tx?

A
  • very common: esp in females
  • track problem: Q angle
  • conservative tx:
    rehab, brace
  • surgery
40
Q

WHat is Osgood Schlatters?

A
  • 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)
41
Q

Presentation of Osgood Schlatters?

A
  • pain at anterior aspect, worse w/ kneeling
  • tender over enlarged tubercle
  • worse w/ resisted extension
42
Q

Tx of Osgood Schlatters?

A
  • NSAIDs, rest, ice, activity modification
  • quad + hamstring strenghening
  • 90% resovle: time limiting
  • for severe sxs: cast
  • rarely reqrs ossicle excision: skeletally mature w/ sxs
43
Q

Foot and ankle exam?

A
  • 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
44
Q

MC injuries in sports?

A
  • 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
45
Q

DDx of twisting injuries of ankle?

A
  • 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
46
Q

Distal tibia, fibula and talus form what jt?

A
  • mortise jt

- held together by anterior, posterior tibiofibular ligament and syndesmosis

47
Q

Primary ligamentous support?

A

lateral ligament complex:

  • ATFL (anterior talofibular ligament)
  • CFL (calcaneofibular ligament)
  • PTFL (posterior talofibular ligament)

medial or deltoid ligament complex

48
Q

Fxn of peroneal tendons?

A
  • 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
49
Q

Fxn of posterior tibialis muscle?

A
  • antagonist to peroneals

- provides resistance to eversion stresses

50
Q

Why are medial ligaments less likely to be injured?

A
  • b/c of the more of prominent bony barriers to eversion

- result from ankle external rotation and eversion

51
Q

MOI of lateral collateral ligaments?

A
  • 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
52
Q

RFs for inversion injuries?

A
  • 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
53
Q

PE for lateral ankle injuries?

A 
- 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
54
Q

Tests for ankle instability?

A

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

55
Q

When is XR warranted for lateral ankle injuries? What views are needed? What are you looking for?

A
  • 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
56
Q

Other dx tests for lateral ankle injuries?

A
  • 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
57
Q

Tx of lateral ankle sprains?

A
  • 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
58
Q

Tx of chronic ankle instability?

A
  • 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
59
Q

What is mechanical and fxnl instability of the ankle?

A
  • 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
60
Q

Ligaments involved in syndesmotic injuries?

A 
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
61
Q

Dx of syndesmotic injuries?

A
  • 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
62
Q

Tx of syndesmotic injuries?

A
  • 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
63
Q

Assessment of persistently painful sprained ankles?

A
  • 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
64
Q

DDx for persistently painful sprained ankles?

A
  • 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
65
Q

What are stress fx? MC occur?

A
  • 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
66
Q

Etiology of stress fx?

A
  • 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
67
Q

Presentation of stress fx?

A
  • 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
68
Q

Dx of stress fx?

A
  • xrays: acutely may not show evidence - may take 10-14 days b/f bone remodeling is present
  • MRI or bone scan is more sensitive
69
Q

Tx of stress fx?

A
  • 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
70
Q

Prevention of stress fx?

A
  • 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
71
Q

Presentation of tibial stress fx? Tx?

A
  • pain directly over fx
  • tx:
    activity restriction w/ protected wt bearing
    rarely IM nail ( only if allowed to develop and not able to heal)
72
Q

Diff types of femoral neck stress fx? Study of choice?

A
  • compression side: inferior medial neck
  • tension side: superior lateral (need surgical tx - worry about AVN)
  • MRI study of choice

Ortho (24 decks)

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