Patellofemoral dysfunction in tennis players. A dynamic problem.

Our mechanically-based dynamic approach to PFD focuses on immediate alteration of symptoms during functional activities. This approach and this article focuses on mechanically-based PFD. The athlete benefits from this approach because if symptom alteration is successful, activity modification may not be necessary. The success of our ability to alter symptoms is an excellent indicator of the athlete's rehabilitation prognosis. Although remaining active is an immediate benefit to the athlete, this program focuses on correction of mechanical faults and musculoskeletal imbalances in an attempt to permanently eliminate symptoms. As noted, diagnosis of PFD is relatively easy to determine, whereas treatment often is both controversial and frustrating. To date, the authors have had great success treating tennis players and other athletes with this approach. We believe that our success rate is an indicator of the value of this program. A standardized yet adaptable approach to treatment and follow-up is recommended to understand the natural course and long term prognosis of these athletes. As we continue to investigate this problem it is clear that there are many unanswered questions about PFD. Many of these questions could be more easily answered if an objective way to classify PFD can be developed, as well as a way to evaluate, treat, and follow-up PFD on a long-term basis. The authors are confident, however, that this functional approach provides a simple and dynamic way to rehabilitate athletes with PFD.

The utility medial portal: a new arthroscopic approach to the knee.

Placement of accurate arthroscopic portals is crucial in arthroscopic knee surgery. Unlike the inferolateral portal that is usually used initially in arthroscopic surgery, the utility medial portal allows excellent visualization of both the medial and lateral compartments as well as the patellofemoral articulation and suprapatellar pouch. Other diagnostic advantages include visualization of the anterior horn of the lateral meniscus, access into the posterior compartment of the knee, and visualization of the intercondylar notch. Surgically, this portal is invaluable in lateral meniscal procedures. Specifically, placement of the arthroscope in the utility medial portal allows access to the complete lateral meniscus, including the anterior and posterior horns, for both visualization and instrumentation. This portal is also outstanding for use in patellofemoral surgical procedures. This portal has been used with great success as a standard arthroscopic portal without difficulty, primarily in 550 arthroscopic procedures and secondarily in 240 procedures. This portal is recommended for examination of the knee in all cases except those in which there is a high suspicion of an isolated medial meniscus tear. Also, the portal may be used routinely for surgical visualization and instrumentation due to its flexibility.

Rehabilitation of the athlete with a knee injury.

Rehabilitation of the athlete with an injured knee is covered. The focus of this article is on identifying, measuring, and treating disorders commonly associated with an injured knee. If available, literature is reviewed that supports approaches suggested. If literature is not available, the authors attempt to justify suggested protocols with logic based on sound biological principles.

Rehabilitation of patellofemoral dysfunction in the athlete.

Patellofemoral dysfunction is a common but not yet well-managed condition affecting a large number of athletes. It is important to perform a thorough evaluation of these athletes including soft-tissue imbalances and faulty movement patterns. It is also important to develop a comprehensive treatment plan that addresses each abnormal component to return the athlete to his or her previous activity.

Electrical stimulation of quadriceps femoris in an elite weight lifter: a single subject experiment.

The response to treatment of high intensity neuromuscular electrical stimulation (NMES) to both quadriceps femoris muscles as an adjunct to ongoing weight training was evaluated using a single subject experimental design. For an elite weight lifter weekly maximal measurements of snatch (S), clean and jerk (CJ), and front squat (SQ) were obtained over 4 months during which the subject weight trained daily for 3 h. The 1st month, baseline data were collected. After baseline measurements, a 1-month period of high-intensity NMES was added to the subject's weight training. NMES was then withdrawn for 1 month and administered once more for 2 weeks. Three quadriceps femoris muscle biopsies were taken, two during the initial baseline period and one just before the end of the first stimulation period. The results showed a significant and clear relationship between performance gains and NMES administration and withdrawal. Steep gains for S, CJ, and SQ were seen after 2 weeks of stimulation, with front squat showing a 20-kg increase within the 1st week of both stimulation periods. Muscle biopsy showed an increased type I fiber area, decreased type IIa and IIb fiber area, and an increase of type II fibers after NMES. The results of this study support the use of high-dose NMES as an adjunct to weight training in elite lifters.

Electrical stimulation versus voluntary exercise in strengthening thigh musculature after anterior cruciate ligament surgery.

Twenty patients who had undergone anterior cruciate ligament reconstructive surgery were placed randomly and independently in an Electrical Stimulation Group (n = 10) or Voluntary Exercise Group (n = 10) to compare the effectiveness of these two muscle-strengthening protocols. Patients in both groups used simultaneous contraction of quadriceps femoris and hamstring muscles during a training regimen that consisted of either voluntary exercise or electrical stimulation trials five days a week for a three-week period within the first six postoperative weeks. After patients completed the training regimen, bilateral maximal isometric measurements of gravity-corrected knee extension and flexion torque were obtained for both groups and percentages were calculated. Results showed that patients in the Electrical Stimulation Group finished the three-week training regimen with higher percentages of both extension and flexion torque when compared with patients in the Voluntary Exercise Group (extension: t = 4.35, p less than .05; flexion; t = 6.64, p less than .05). These results indicate that patients in an electrical stimulation regimen can achieve higher individual thigh musculature strength gains than patients in a voluntary exercise regimen when simultaneous contraction of thigh muscles is prescribed during an early phase of postoperative rehabilitation.

Shoulder pain in the competitive tennis player.

Shoulder pain in the elite tennis player is of the overuse variety and is usually attributable to impingement symptoms. Nonoperative approaches favor the quickest return to competitive tennis, and when surgery is necessary, arthroscopic procedures are preferred.

Stretching, strengthening, and conditioning for the competitive tennis player.

For an athlete to be competitive at the highest levels of tennis, he or she must possess an optimal level of flexibility, strength, and cardiovascular conditioning. He or she also must be at a maximum level in areas including upper and lower extremity selective endurance, isolated muscular strength patterns of repetitive activities, and agility. To achieve this, a great deal of time and effort must be spent off the tennis court strengthening the appropriate muscle groups and improving overall agility and pattern responses. It is hoped that these programs will allow the American junior tennis player to return to a level competitive with the rest of the world.

Surface and equipment variables in tennis injuries.

Alterations in equipment can reduce the incidence and severity of overuse injuries in the competitive tennis player. Changes in racquet variables, court surface, footwear, and string tension play an important part in treatment of both upper and lower extremity injuries. Adequate time for rehabilitation is needed to prevent reinjury when returning to competition.

Thoracoabdominal musculoskeletal injuries in racquet sports.

Thoracoabdominal musculoskeletal injuries are separated into rectus abdominus injuries and lower thoracic muscular injuries. Localized rectus injuries may be treated by steroid injection. Diffuse rectus injuries and thoracic injuries are treated by aggressive rehabilitation. The mechanisms of injury are different in each case, and prevention of these forces is necessary to allow soft-tissue healing.

A modified Bristow-Helfet-May procedure for recurrent dislocation and subluxation of the shoulder. Report of two hundred and twelve cases.

A modified Bristow-Helfet-May procedure was performed for recurrent dislocation or subluxation of the glenohumeral joint in 207 patients (212 shoulders), whose average age at the time of surgery was 20.3 years (range, fourteen to forty-seven years). The procedure was modified by directing the coracoid segment and conjoined tendon over the superior border rather than through the substance of the subscapularis tendon and muscle. The indications were either documented recurrent anterior dislocation of the glenohumeral joint or subluxation with instability as demonstrated on examination with the patient under anesthesia. The procedure was evaluated on the basis of the rate of recurrence of dislocation and subluxation, postoperative complications, the patients' subjective evaluation, and the effect of the procedure on the motion of the glenohumeral joint and the strength of the muscles of the shoulder as related to overhead throwing. Eight (3.8 per cent) of the shoulders redislocated and ten (4.7 per cent) had one or more subjective episodes of subluxation after the procedure. Complications included postoperative infection in two patients and problems with the screw that required its removal in ten. One hundred and thirty-one (62 per cent) of the patients responded to a questionnaire regarding their subjective evaluation of the results of surgery. Eleven (8 per cent) were unable to perform daily activities that involved overhead work, and forty-five (34 per cent) stated that they still had some degree of discomfort or pain in the shoulder. One hundred and twenty-six patients (96.2 per cent) stated that they were happy with the results of the surgery and would have the procedure again. Thirty patients had Cybex testing of the muscles of the shoulder. Only three (16 per cent) of the nineteen athletes whose dominant arm had been operated on returned to their pre-injury level of throwing. Data obtained with regard to changes in the range of motion and strength of the glenohumeral joint indicate that this loss of throwing ability was not due solely to a loss of glenohumeral motion. It appeared to be also related to a concomitant loss of strength at the extreme of external rotation of the humerus and the initiation of internal rotation of the humerus.

Fractures of the base of the fifth metatarsal distal to the tuberosity: a review.

Fractures of the proximal part of the fifth metatarsal can be separated into two types: those involving the tuberosity, and those involving the proximal part of the diaphysis distal to the tuberosity. Recently it has been recognized that the latter group, Jones' fractures, may be difficult to treat. Although reports in the literature have indicated the potential difficulties in the treatment of Jones' fractures, prevailing guidelines for their management are ambiguous. Apparently the varied clinical and roentgenographic manifestations of these fractures have not been correlated with their response to treatment. In this paper we describe a classification of these fractures and a plan of treatment based on clinical and roentgenographic criteria that were developed to define acute fractures, delayed unions, and nonunions. The treatment of choice for acute fractures is immobilization of the limb in a toe to knee cast with nonweight-bearing. Fractures with delayed union may eventually heal if they are treated conservatively, but an active athlete with delayed union or an established nonunion will benefit from operative intervention. The procedures of choice are medullary curettage and bone grafting, and closed axial intramedullary screw fixation using a 4.0-mm ASIF malleolar screw.

Field evaluation and management of head and neck injuries.

This article presents clear, concise guidelines for classification, evaluation, and emergency management of injuries that occur to the head and neck as a result of competitive and recreational sports. There are several principles that must be considered by individuals responsible for an athlete who sustains a serious head or neck injury: a person who "captains" the medical/first-aid team; knowledge of the appropriate emergency management techniques; availability of emergency medical equipment including a spine board, telephone, and ambulance; and a clear understanding of the philosophy that emergency management should "do no further harm."

Osteochondritis dissecans of the midfoot.

Osteochondritis dissecans of the midfoot is described with discussion focusing on its etiology, classification, and treatment. Two cases are presented in which workup, treatment, and follow-up are described. Difficulty in making the diagnosis is caused by a lack of awareness of this entity and the specific studies needed to identify the lesion.

Effect of fixation devices on radiostrontium clearance in the intact canine femur.

Femoral metaphyseal/diaphyseal blood flow was studied by 85Sr clearance in unfractured segments of dog femurs following compression plating and various control procedures (drilling with and without application of screws). The animals were tested as early as seven days and as late as two months after surgery. The only statistically significant change in strontium clearance (SrC) was an increase produced by the application of stainless-steel bone screws, with or without plates. The presence or absence of compression had no consistent effect on changes in the rate of SrC. During the period of study, no changes in bone mineralization, haversian porosity, or cortical bone thickness accompanied the SrC alterations.