The Role of the Hand Surgery Consultant in the Care of the Football Athlete.

PURPOSE: Return-to-play safely focusing on care for professional athletes. Variability on when return-to-play is possible due to differences in dexterity requirements of player's position and upper extremity injuries. This study covers the importance of trust between players and healthcare providers in the incident of upper extremity injury and aspects of when return-to-play is favorable. MATERIAL AND METHODS: The methods and materials used in this study were a collection of case reviews and documentation of injuries reported by national leagues. A retrospective review from 2000 to 2012 reviewing case series reported by the NFL Injury Surveillance System (NFL ISS). The case reviews included player activity, external bracing, and clinical notes. The review extracted from the National football league surveyed injuries over a 10-year period from 1996 - 2005. The National Football league's surveillance database was used focusing on the type of injury, the athlete's position, and the type of activity that was occurring at the time of injury. RESULTS: The 7 included articles reported most injuries occurred in defensive players. The majority of injuries were sustained while tackling. Additionally, the 7 articles included a discussion of injury types including those of the hand, wrist, forearm, and elbow. Treatment plans were also reviewed catering to the type of injury. Players who were treated non-operatively missed a mean of 25 days and players who were treated operatively missed a mean of 46 days. CONCLUSION: The importance of communication between surgeons, coaches, players, and general managers of teams is vital in caring for injured players. All parties need to be aware of how much time players will miss and the best management techniques to take to get them back on the playing field.

Traumatic Carpal Axial Instability in a Professional Football Player: A Case Report.

This is a case of traumatic carpal axial instability in a professional football player. Traumatic carpal axial instability characteristically involves longitudinal separation of the ulnar or radial distal carpal row along with intermetacarpal injury. Rarely, pancarpal ligament disruption occurs, as in this case. Early diagnosis and treatment of unstable wrist injuries is important in achieving a satisfactory outcome.

Lateral antebrachial cutaneous nerve compression after traumatic rupture of the long head of the biceps: a case series.

BACKGROUND: Lateral antebrachial cutaneous (LABC) nerve compression is a rare but debilitating injury. There are limited data on the association of LABC nerve compression and proximal biceps rupture. We theorized that because of distal migration, the biceps muscle and tendon cause compression on the nerve. METHODS: We present 2 cases in which patients had proximal biceps ruptures with tendon retraction and developed neurologic symptoms associated with the LABC nerve. To demonstrate our theory, we performed a cadaveric experiment. After making an incision to expose the entire biceps muscle and the musculocutaneous nerve and its branch into the LABC nerve, we marked each structure in 2-cm increments with a marking pen. The long head of the biceps was then cut to simulate a proximal biceps rupture. RESULTS: The relationship between the 3 structures was then studied, showing no change in position of the musculocutaneous nerve or LABC nerve. The biceps muscle and tendon had migrated distally toward the LABC nerve, demonstrating compression of the nerve. CONCLUSION: Proximal biceps tears commonly occur from trauma as well as iatrogenically after a biceps tenotomy for treatment of biceps tendinopathy. However, it is unusual for neuropathy of the LABC nerve to occur. Patients who develop neuropathy associated with the LABC nerve after a proximal biceps rupture can be effectively treated with LABC nerve decompression and biceps plasty. We found that this was an effective surgical treatment of LABC neuropathy without the need for proximal biceps tenodesis.

Efficacy of platelet-rich plasma for chronic tennis elbow: a double-blind, prospective, multicenter, randomized controlled trial of 230 patients.

BACKGROUND: Elbow tenderness and pain with resisted wrist extension are common manifestations of lateral epicondylar tendinopathy, also known as tennis elbow. Previous studies have suggested platelet-rich plasma (PRP) to be a safe and effective therapy for tennis elbow. PURPOSE: To evaluate the clinical value of tendon needling with PRP in patients with chronic tennis elbow compared with an active control group. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: A total of 230 patients with chronic lateral epicondylar tendinopathy were treated at 12 centers over 5 years. All patients had at least 3 months of symptoms and had failed conventional therapy. There were no differences in patients randomized to receive PRP (n = 116) or active controls (n = 114). The PRP was prepared from venous whole blood at the point of care and contained both concentrated platelets and leukocytes. After receiving a local anesthetic, all patients had their extensor tendons needled with or without PRP. Patients and investigators remained blinded to the treatment group throughout the study. A successful outcome was defined as 25% or greater improvement on the visual analog scale for pain. RESULTS: Patient outcomes were followed for up to 24 weeks. At 12 weeks (n = 192), the PRP-treated patients reported an improvement of 55.1% in their pain scores compared with 47.4% in the active control group (P = .163). At 24 weeks (n = 119), the PRP-treated patients reported an improvement of 71.5% in their pain scores compared with 56.1% in the control group (P = .019). The percentage of patients reporting significant elbow tenderness at 12 weeks was 37.4% in the PRP group versus 48.4% in the control group (P = .143). Success rates for patients at 12 weeks were 75.2% in the PRP group versus 65.9% in the control group (P = .104). At 24 weeks, 29.1% of the PRP-treated patients reported significant elbow tenderness versus 54.0% in the control group (P = .009). Success rates for patients with 24 weeks of follow-up were 83.9% in the PRP group compared with 68.3% in the control group (P = .037). No significant complications occurred in either group. CONCLUSION: No significant differences were found at 12 weeks in this study. At 24 weeks, however, clinically meaningful improvements were found in patients treated with leukocyte-enriched PRP compared with an active control group.

Platelet-Rich Plasma in Addition to Rehabilitation for Acute Hamstring Injuries in NFL Players: Clinical Effects and Time to Return to Play.

BACKGROUND: Platelet-rich plasma (PRP) injections have been proposed to hasten soft tissue healing. There is a lack of evidence in the current literature to support their efficacy in elite athletes. PURPOSE: To investigate the effects of the addition of PRP to rehabilitation in the treatment of acute hamstring injuries in professional National Football League (NFL) players and to report the time to return to play. STUDY DESIGN: Case control study. METHODS: Ten NFL players with similar hamstring injury patterns were retrospectively divided into 2 groups. The treatment group (PRP; n = 5) was injected with PRP and the control group (non-PRP; n = 5) was not injected; both groups completed a rehabilitation program. The PRP injections were administered under ultrasound guidance with precise localization of the injury site, within 24 to 48 hours of injury. Age, muscle involved, extent of injury, grading, and time to return to play were noted. Descriptive statistics and the exact Wilcoxon rank-sum test were used for data analysis. RESULTS: The mean age was 23 years (range, 22-27 years) for the PRP group and 26 years (range, 22-28 years) for the non-PRP group (P = .42). The median longitudinal extent of the injury was 14 cm (range, 9-18 cm) in the PRP group and 15 cm (range, 9-16 cm) in the non-PRP group (P = .77). The average transverse extent of the injury in the PRP and non-PRP groups was 4 cm (range, 1.6-6 cm) and 3.5 cm (range, 2-5 cm), respectively, and the respective average anteroposterior extent was 4 cm (range, 1.9-5 cm) and 2.9 cm (range, 1.5-4 cm). The long head of biceps femoris was most commonly involved (4 in each group), with a single tear of the semimembranosus in each group. The median injury classification was grade 2 in both groups. The median time to return to play was 20 days (range,16-30 days) in the PRP group and 17 days (range, 8-81 days) in the non-PRP group (P = .73). CONCLUSION: There were no significant differences in recovery from hamstring injury between treatment with PRP and routine rehabilitation. A larger, randomized controlled trial is warranted.

Anatomic reconstruction of thumb metacarpophalangeal joint ulnar collateral ligament using an interference screw docking technique.

Complete rupture of the ulnar collateral ligament injury of the thumb metacarpophalangeal (MCP) joint can be a debilitating injury resulting in decreased grip and pinch strength. The spectrum of injury to this ligament varies from simple strain to complete rupture of both proper and accessory ligaments. Generally, this is a result of an abduction force transmitted across the thumb MCP joint.Physical examination assists in identification of these injuries and the extent of ligamentous injury. Ecchymoses and pain over the ligament are usually present in the acute injury. Chronic injuries may not be painful. A palpable mass may be present. The valgus stress test across this joint in 30 degrees of flexion provides information on the competency of the proper ligaments, whereas valgus stress in extension assesses the accessory collateral ligaments. This stress test is useful in the acute or chronic setting.Stabilization of the thumb MCP joint in chronic injuries can require reconstruction. We describe an anatomic reconstruction using a tendon graft and a bioabsorbable interference screw.

Proximal femoral stress reaction in a professional football player.

There have been no previous case reports of femoral stress fractures in professional football players. We present a professional defensive back who presented 1 week after noting mild soreness in the right proximal thigh during practices, prior to a regular season game. Early diagnosis of a stress reaction was made with magnetic resonance imaging (MRI). Magnetic resonance imaging is an excellent imaging modality for stress reactions/fractures given its high sensitivity, specificity, and ability to image surrounding soft tissues. Short tau inversion recovery and fat-suppressed images are best for seeing early osseous edema. Early detection of this injury allowed us to hasten the recovery and prevent further injury. The patient was treated successfully with early nonweight bearing, a gradual increase in activity via cross training, and a structured functional progression to return to play. Normalization of MRI lagged behind the player's healing and was not necessary to determine advancement of rehabilitation or return to play. Three main issues are important to review in this case of a proximal femoral stress injury: early diagnosis is the key to treatment and early return to play; imaging studies lag behind clinical symptoms; and the treatment regimen should consist of a period of rest and be tailored to the individual.

Nonunion of olecranon stress fractures in adolescent baseball pitchers: a case series of 5 athletes.

BACKGROUND: Adolescent athletes participating in overhead throwing sports suffer a variety of overuse elbow injuries, many of which have been well described in the literature. Nonunion stress fractures of the olecranon across the epiphyseal plate, however, have received little attention. PURPOSE: To describe this unusual clinical entity in the differential diagnosis of the adolescent athlete with elbow pain and to demonstrate that operative treatment is an effective means of quickly and safely returning the patient to sporting activities. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Five adolescent baseball pitchers (mean age, 15 years) who suffered chronic elbow pain and who were diagnosed with olecranon epiphyseal stress fracture nonunions were treated with open reduction and internal fixation using a 7.0 cancellous screw and washer with or without 18-gauge tension banding. RESULTS: Return to preoperative range of motion was achieved at a mean of 8.6 weeks (range, 3.4-16.6 weeks). Patients were clinically asymptomatic at a mean of 11 weeks (range, 7.7-13.6 weeks) after surgery. Radiographic evidence of stress fracture union was achieved at a mean of 15.4 weeks (range, 6.1-33 weeks), including 1 patient with a delayed union according to radiographs, which healed at 33 weeks. Patients were started on a light strengthening program at 5 to 7 weeks and a throwing progression program at 15.6 weeks (range, 6.4-28.1 weeks). All 5 patients were able to return to their previous level of activities, with a mean return time of 29.4 weeks (range, 18.9-40.4 weeks). CONCLUSION: Surgical management of olecranon apophysis stress fractures provided excellent results with minimal complications in this series of 5 consecutive cases.

Potential risk of rerupture in primary achilles tendon repair in athletes younger than 30 years of age.

BACKGROUND: Complete Achilles tendon ruptures are found more often in athletes who participate in sports involving explosive acceleration or maximal effort. In most studies, the consensus for athletes is surgery. This form of treatment has been shown to exhibit the best functional performance with a lower rerupture rate. HYPOTHESIS: Achilles tendon ruptures in a young population (<30 years) have a higher rerupture rate than similar injuries in an older age group (31-50 years), in which the injury is more common. STUDY DESIGN: Cohort study; Level of evidence, 4. METHODS: Retrospective study was carried out by chart review. Magnetic resonance images were obtained comparing appearance of repair in young and old patients at 8 to 12 weeks after operation. RESULTS: There were a total of 4 reruptures in the 89 Achilles tendon repairs. This was an overall rerupture rate of 4.5%, which was consistent with the literature. When the reruptures were critically analyzed, it was noted that the 4 reruptures of the repaired tendon occurred in a young population. Of the 89, there was a subgroup of athletes (n=24) who were 30 years of age or younger at the time of injury. The incidence of rerupture for these individuals was 16.6%. In the remaining athletes (n=65) older than 30 years, the incidence of rerupture was zero. There were no significant differences (P < or =.05) in all parameters measured (average days in a boot, average days to active range of motion, average time to full weight-bearing, average days to bike or use a stair climbing machine, average return to sports) between age groups except in the time from injury to surgery (7.1 days, for athletes < or =30 years vs 2.65 days for athletes >31 years). CONCLUSIONS: The results of Achilles tendon repair with an early weightbearing and an early range of motion rehabilitation program are good. However, caution may need to be taken in the younger athlete (< or =30 years) during rehabilitation. CLINICAL RELEVANCE: Although the authors recommend aggressive rehabilitation for Achilles tendon repairs, caution should be observed in the younger athlete.

Athletic injuries of the wrist and hand: part II: overuse injuries of the wrist and traumatic injuries to the hand.

Hand and wrist injuries in sports are some of the most common injuries reported. This review discusses common overuse injuries of the wrist including tendon injuries such as de Quervain's syndrome, subluxation of the extensor carpi ulnaris, and the common dorsal carpal impingement syndrome. The main focus of this section is the discussion of traumatic injuries to the hand in the athlete. Included is a discussion and review of fractures of the phalanges and metacarpals, common proximal interphalangeal joint injuries, and thumb carpal metacarpal and metacarpophalangeal joint injuries. Emphasis is placed on more common injuries seen regarding diagnosis, indications for non-operative versus operative treatment, and time to return to athletic competition.

Athletic injuries of the wrist and hand. Part I: traumatic injuries of the wrist.

Hand and wrist injuries in sports are some of the most common injuries reported. This review discusses briefly the causes of hand and wrist injuries in sports and discusses pertinent biomechanical findings regarding the range of motion required in different sports activities. The bulk of the review discusses specific traumatic and overuse injuries to the hand and wrist commonly seen in the athlete. Emphasis is placed on problematic traumatic injuries such as carpal scaphoid fractures and hook of the hamate fractures, as well as ligament injuries to the wrist with regard to diagnosis, treatment, and return to athletic competition.

Full-thickness rotator-cuff tears in professional football players.

A survey was sent to team physicians in the National Football League to investigate the number of full-thickness rotator-cuff tears occurring in professional football players and to assess treatment of these injuries. Fifty-one full-thickness tears in 49 players were reported. Offensive linemen and linebackers were most commonly affected; 2 linemen sustained bilateral tears. The most common mechanism of injury was a fall onto the shoulder.

Traumatic elbow injuries in the athlete.

Traumatic injuries to the elbow are not uncommon in the athlete. A fall onto the out-stretched arm may result in fracture of the radial head, dislocation of the elbow, or other injuries about the joint. Strength training and contact sports may cause rupture of the biceps or triceps tendon at the elbow. It is important for the sports medicine physician to become familiar with injury patterns about the elbow in athletes and treatment options. This article will be devoted to a summary of classification, diagnosis, and treatment considerations for selected traumatic athletic injuries of the elbow.

Wrist Injuries.

In brief Wrist pain in an active patient is a physician's cue to look for specific clues in the history, physical exam, and diagnostic tests. Without prompt diagnosis and accurate treatment, the chronic pain can impair sports participation and performance. And in certain instances, a misdiagnosed condition, such as a carpal dislocation or distal radial physeal fracture, can lead to deformity or disability from lack of adequate treatment.

Perfecting a Playing Cast for Hand and Wrist Injuries.

In brief In 21 years of treating patients who had hand and wrist injuries by using silicone rubber playing casts, clinicians have found that these casts effectively protect athletes during competition. The authors describe a straightforward method of fabricating a silicone rubber cast that allows athletes to return to play quickly. In a survey of 148 high school football players, athletes reported that the cast was safe and functional.