Upper extremity overuse injuries in swimming. A discussion of swimmer's shoulder.

Treatment of shoulder pain includes the following: 1. Avoid all painful activities. 2. A 2-week course of nonsteroidal anti-inflammatory medication and ice. 3. Decreased anterior capsule stretching and increased posterior capsule stretching. 4. Increased rotator cuff exercise with emphasis on external rotators. 5. Scapular-positioning muscle exercises and increasing body roll. Shoulder pain can be prevented by the following: 1. Avoid all painful activities, and notify coach of shoulder pain immediately. 2. Do not use nonsteroidal anti-inflammatory medications or ice on a chronic basis. 3. Spend equal time stretching the posterior and anterior capsules. 4. Perform general rotator cuff exercises. 5. Perform scapular-positioning muscle exercises, with emphasis on body roll. [figure: see text] Shoulder pain in swimmers is common and can be debilitating. Most of the pain is caused by instability, which stems from swimming-specific demands that increase performance but decrease shoulder stability. These sport-specific demands are (1) increased shoulder range of motion, (2) increased internal rotation and adduction strength, and (3) prolonged, fatiguing, shoulder-intensive training. Instability leads to [figure: see text] inflammation and pain and can become a self-perpetuating process. Treatment consists of patient education, cessation of all activities that cause pain, activity modifications to increase shoulder stability, and pharmacologic treatment of the inflammation. In patients who do not improve using this regimen, surgery can be of benefit, either to reduce capsular laxity or to remove chronic inflammation and scar tissue. The patient must be aware of the risk of decreased performance.

Injuries in competitive swimming.

Competitive swimming is commonly thought to be an injury-free sport. Traumatic and overuse injuries do occur, especially if one includes accidents occurring to both athletes and spectators, and accidents resulting from some of the newer diving and starting techniques. United States Swimming, Incorporated, the national governing body for competitive swimming, and provider of insurance coverage for most of the swimming clubs in the United States, keeps track of reported injuries to club members, and requires specific safety accreditation for member coaches. These data provide an informative view on injuries to competitive swimmers.

Thoracic outlet syndrome in aquatic athletes.

Thoracic outlet syndrome is a well-recognized group of symptoms resulting from compression of the subclavian artery and vein, as well as the brachial plexus, within the thoracic outlet. Symptoms are related directly to the structure that is compressed. Diagnosis is difficult because there is no single objective, reliable test; therefore, diagnoses of thoracic outlet syndrome is based primarily on a set of historical and physical findings, supported and corroborated by a host of standard tests. Because aquatic athletes are primarily "overhead" athletes, one may expect a higher incidence of thoracic outlet syndrome in this population. The differential between TOS and "swimmer's shoulder" (multidirectional instability and subacromial impingement) may be difficult. Nonsurgical treatment methods can be helpful in relieving symptoms; in certain recalcitrant cases, however, surgical intervention can provide lasting relief and a return to aquatic athletics.

Late patellar tendon ruptures after removal of the central third for anterior cruciate ligament reconstruction. A report of two cases.

Patellar tendon rupture after removal of the central third for ACL reconstruction is a rare complication. Only nine cases have been previously reported, and all of these occurred within the first 10 months after surgery. We report two cases of late patellar tendon ruptures occurring at more than 3 and 6 years, respectively, after surgery. A review of the literature has suggested but not conclusively supported that devascularization, an alteration in tendon healing and remodeling, or injury to the remaining tendon at the time of graft harvest may be possible causes of this rare complication. Biopsy tissue from any future patellar tendon ruptures after removal of its central third could contribute to a better understanding of this anomaly.

The ligament augmentation device in hamstring grafts for reconstruction of the anterior cruciate ligament.

Twenty-eight patients who had reconstructions of the anterior cruciate ligament with a ligament augmentation device in the semitendinosus and gracilis tendons were compared with 32 patients who had reconstructions with semitendinosus and gracilis tendons alone. Preoperatively, there was no significant difference between the 2 groups with respect to age, sex, Tegner activity level, and time from injury to operation. Mean postoperative followup was 31.4 months for the augmentation group and 32.3 months for the nonaugmentation group. At postoperative evaluation, there was no difference in the 2 groups with respect to Lysholm knee scores, return to activity as measured by Tegner levels, KT-1000 arthrometer laxity testing, presence of pivot shift or Lachman sign, range of motion, and the patient's subjective overall rating of the surgery. Twenty-six of the 28 patients (93%) with augmentation rated their results as either "good" or "excellent" compared with 30 of the 32 patients (94%) with no ligament augmentation who rated their results as good or excellent. Four patients with the ligament augmentation devices needed reoperation for recurrent effusions and pain. No patients in the nonaugmentation group had recurrent effusions.

The effects of ice on blood flow and bone metabolism in knees.

The effects of an ice wrap, applied to a knee for 20 minutes, on blood flow and bone metabolism were measured using triple-phase technetium bone scans. Twenty-one subjects between 29 and 63 years of age were studied. A commercially available ice wrap was applied to one knee 20 minutes before scanning, while an identical wrap left at room temperature was applied to the opposite knee to act as a control. Scans of the knees were obtained at the completion of cooling, and the images were quantified by computer image analysis for each knee at each phase of the scan. Percentage of decrease in blood flow and subsequent bone uptake of technetium for the iced knee as compared with the opposite knee were calculated. All iced knees demonstrated decreased arterial and soft tissue blood flow as well as decreased bone uptake, which is a reflection of changes in both bone blood flow and metabolism. The average decrease was 38.4% +/- 4.97 in arterial blood flow, 25.8% +/- 2.04 in soft tissue blood flow, and 19.3% +/- 2.0 (standard error of the mean in each) in bone uptake. This "ice effect" was not related to age, sex, knee circumference, or skin temperature after cooling. By decreasing blood flow and cell metabolism, ice theoretically can limit hemorrhage and cell death in the setting of acute traumatic injury. This study thus provides a scientific rationale for the use of ice as tested for such injuries to a large joint, whether in the soft tissues or bones.

Bilaterally painful anomalous insertion of the medial meniscus in a volleyball player with Marfanoid features.

A female volleyball player with a Marfanoid habitus had bilateral symptomatic anomalous insertions of the medial meniscus. Arthroscopic resection of the anomalous portions of the medial menisci as they attached to the anterior cruciate ligament successfully eliminated her symptoms.

Swimming and the older athlete.

Swimming is an organized, fast-growing sport and competitive swimmers are now found in abundance in all age groups. Including those athletes who do not compete in formal events (masters swimming program) and those participating in outside events (long-distance, channel swimming, triathlons, and so on), it may be one of the largest participant sports in this country. Injuries to the elite collegiate competitive swimmers have been well-documented. Considerations and injuries to the masters-level swimmer closely mirror those found in the younger athlete, but these injuries reflect the impact of tissue aging (degenerative disease). The preparticipation history and physical examination become more important. We are hopeful that this article will contribute to greater safety and enjoyment among all older swimmers.

TSRH instrumentation: evolution of a new system. Part 1. Texas Scottish Rite Hospital.

The TSRH System was designed at Texas Scottish Rite Hospital for Crippled Children in Dallas, Texas, to correct spinal deformities in a three-dimensional plane. The system's greatest advantage is its application in spinal revisions. The other advantage to the TSRH system is the crosslink system used in linking paralleling rods for spinal fusion. The TSRH spinal system is paralleled to the Cotrel-Dubousset (CD) system. Advantages of both systems are discussed in this article.

Rupture of the pectoralis major muscle.

Nineteen cases of rupture of the pectoralis major muscle are presented. In 16 cases the rupture was repaired; in 3 cases repair was not performed. Physical findings and surgical technique are described and the anatomy of the insertion of the pectoralis major muscle is reviewed. Nine of the patients in this series sustained their injury while performing the bench press. The majority of the remaining patients were also involved in sports when injury occurred. Eleven of the ruptures were in the nondominant arm and eight in the dominant arm. All of the patients complained of weakness, pain, and deformity, with weakness being the major complaint. Following surgery and rehabilitation, all 16 patients who underwent repair were relieved of pain. The deformity was corrected in all 16 patients, although 2 patients who had a 5 year interval from repair to rupture did not achieve a completely normal contour. Thirteen of the 16 patients reported a full return to strength. The others had significant improvements. Ruptures of the pectoralis major muscle are uncommon, but not rare. Ruptures occurring under tension tear at or near the insertion onto the humerus, as in all 19 cases in this series. Distal ruptures are usually complete, despite physical signs that may be misleading. Distal tears are reparable, even after a delay to treatment. After surgical repair, the majority of patients may expect relief of pain, return of strength and normal contour, and maintenance of range of motion.

Orthopedic aspects of competitive swimming.

Orthopedic problems related to competitive swimming are rarely disabling, but can be problematic in preventing training and competition. Most problems are related to the shoulder and knee. Treatment is primarily nonsurgical and directed at relieving symptoms and allowing the athlete to continue with swimming practice. Treatment aids such as ice packing, anti-inflammatory medications, muscle stimulation and electrogalvanic stimulation, strengthening exercises, and static stretching are encouraged; upper arm bands and patellar-stabilizing supports can be adapted to training routines.

Overuse syndromes in baseball, tennis, gymnastics, and swimming.

The shoulder is the "center of action" for most sports including those discussed in this article. Overuse problems of the shoulder are the most common group of injuries affecting the athlete involved in baseball, tennis, swimming, and gymnastics. Most of the injuries can be directly related to the mechanics of throwing, swimming, or gymnastics. After diagnosis, treatment is directed at "selective rest" of the injured shoulder and modalities and medications intended to decrease the inflammatory response of the body to stress.

Surgical management of resistant congenital talipes equinovarus deformities.

We evaluated the results of surgery for resistant congenital talipes equinovarus deformity in 164 children (244 feet). No patient was followed for less than two years. They were divided into three groups for analysis, based on their treatment. Group 1 consisted of seventy-five children (112 feet) who had incomplete releases only; Group 2 consisted of twenty-three children (thirty-nine feet) who had had a failed incomplete release followed by a one-stage complete posteromedial plantar release, without internal fixation, and serial application of casts; and Group 3 consisted of sixty-six children (ninety-three feet) who had the complete posteromedial plantar release as the initial surgical procedure. Group 1 had 42 per cent, Group 2 had 79 per cent, and Group 3 had 86 per cent satisfactory (excellent or good) long-term results. The radiographic measurements that correlated best with the clinical results were the anteroposterior talocalcaneal overlap, the lateral talocalcaneal angle, and the positions of the navicular and calcaneus. The results in our series emphasize the complex interrelationship of the pathological anatomy and the need for complete simultaneous release of all components of the deformity.

The shoulder in competitive swimming.

Shoulder pain is the most common orthopaedic problem in competitive swimming. In a group of 137 of this country's best swimmers, 58 had had symptoms of "swimmer's shoulder." Population characteristics of this group indicated that symptoms increased with the caliber of the athlete, were slightly more common in men, and were related to sprint rather than distance swimming. The use of hand-paddle training exacerbated symptoms, which were more common during the early and middle season. Consideration of shoulder mechanics in swimming reveals that freestyle, butterfly, and backstroke require similar motions; a swimmer using any of these strokes is susceptible to developing shoulder pain. Swimmer's shoulder represents chronic irritation of the humeral head and rotator cuff on the coracoacromial arch during abduction of the shoulder, the so-called impingement syndrome. Treatment included stretching, rest, ice therapy, oral antiinflammatory agents, judicious use of injectable steroids, and surgery as a last resort.