Injuries about the shoulder in skiing and snowboarding.

There has been a decrease in the overall injury rate, particularly the rate of lower-extremity injuries, for alpine skiing, with a resultant increase in the ratio of upper-extremity to lower-extremity injuries. The upper extremity is injured nearly twice as often during snowboarding than alpine skiing, with approximately half of all snowboarding injuries involving the upper extremity. Shoulder injuries are likely under-reported, as many patients seek evaluation for minor shoulder injuries with their local physicians, and not at the ski medical clinic, where most epidemiology studies obtain their data. Shoulder injuries account for 4 to 11% of all alpine skiing injuries and 22 to 41% of upper-extremity injuries. During snowboarding, shoulder injuries account for 8 to 16% of all injuries and 20 to 34% of upper-extremity injuries. Falls are the most common mechanism of shoulder injury, in addition to pole planting during skiing and aerial manoeuvres during snowboarding. Common shoulder injuries during skiing and snowboarding are rotator cuff strains, glenohumeral dislocations, acromioclavicular separations and clavicle fractures. It is still unclear, when comparing snowboarding and skiing injury data, which sport has the higher incidence of shoulder injuries. Stratifying shoulder injuries by type allows better delineation as to which sport has an increased incidence of certain injury patterns. The differing mechanisms of injury combined with distinct equipment for each sport plays a role in the type and frequency of shoulder injuries seen in these two subgroups. With the increased ratio of upper- to lower-extremity injuries during alpine skiing and the boom in popularity of snowboarding, shoulder injuries are seen with increasing frequency by those who care for alpine sport injuries. According to recent epidemiological data, only clavicle and humerus fractures have shown increased rates of incidence among alpine skiers. Over the past 30 years, there has been a general decrease in both upper- and lower-extremity injuries which can be attributed to improved designs of protective equipment, increased awareness of injury patterns and emphasis on prevention. In the future, physicians and therapists who treat this population must be comfortable and confident in their treatment algorithms to help keep skiers and snowboarders conditioned and ready for the slopes and develop strategies for the prevention of upper-extremity injuries associated with these activities.

Postero-medial elbow problems in the adult athlete.

The ligamentous, osseous, musculotendinous, and neural structures at the postero-medial side of the elbow are at risk for various injuries in overhead athletes. The combination of valgus and extension overload during overhead activities results in tensile forces along the medial stabilising structures, with compression on the lateral compartment and shear stress posteriorly. The combination of tensile forces medially and shear forces posteriorly can result in ulnar collateral ligament (UCL) tears, flexor-pronator mass injuries, neuritis of the ulnar nerve, posterior impingement, and olecranon stress fractures. Most symptomatic conditions of the overhead athlete can be treated conservatively initially. In cases where conservative treatment is unsuccessful surgical intervention is indicated. Recent advances in arthroscopic surgical techniques and ligamentous reconstruction ensure that the prognosis for return to pre-injury level is good.

Shoulder proprioception in baseball pitchers.

We examined proprioceptive differences between the dominant and nondominant shoulders of 21 collegiate baseball pitchers without a history of shoulder instability or surgery. A proprioceptive testing device was used to measure kinesthesia and joint position sense. Joint position sense was significantly (P =.05) more accurate in the nondominant shoulder than in the dominant shoulder when starting at 75% of maximal external rotation and moving into internal rotation. There were no significant differences for proprioception in the other measured positions or with kinesthesia testing. Six pitchers with recent shoulder pain had a significant (P =.04) kinesthetic deficit in the symptomatic dominant shoulder compared with the asymptomatic shoulder, as measured in neutral rotation moving into internal rotation. The net effect of training, exercise-induced laxity, and increased external rotation in baseball pitchers does not affect proprioception, although shoulder pain, possibly due to rotator cuff inflammation or tendinitis, is associated with reduced kinesthetic sensation.

Musculoskeletal injuries in the young tennis player.

Tennis is becoming increasingly popular, especially with young athletes. Despite recent advances in epidemiologic research of tennis injuries, there still is a need for more injury research in all of the racquet sports. The data that does exist show that the young athlete is susceptible to injury in these different sports. Injury patterns in the skeletally immature racquet sports athlete are becoming apparent. Although most of the sports result in similar injury patterns, such as a predominance of lower extremity injury, there are differences. It appears that the physical demands of the sport are becoming more clearly documented, and the adaptive response to these demands is becoming understood. The adaptive response reveals a common origin for many of the injuries in the different sports. This is related most often to repetitive microtrauma with resultant loss in flexibility and strength. The sports medicine practitioner must understand these differences, know the demands, do serial musculoskeletal evaluations for maladaptations, and adhere to a periodized prehabilitation program of preventative exercises to maximize performance and minimize injury risk.

Zoster paresis of the shoulder. Case report and review of the literature.

More than 95% of people in the United States are infected with the varicella zoster virus at some time in life, and this infection usually is manifested as chicken pox during childhood. The virus then establishes a latent infection of sensory ganglia, from which it may reactivate many years later to cause herpes zoster (shingles), a cutaneous painful rash along a dermatomal distribution. Less commonly, the varicella zoster virus may result in myotomal motor weakness or paralysis in addition to a painful dermatomal rash. A case of unilateral left C5-C6 segmental paresis attributable to herpes zoster in an otherwise healthy individual and a current review of the literature are presented. A case of zoster paresis of the shoulder muscles is presented to remind the orthopaedic community that this diagnosis may be confused with other diagnoses, including rotator cuff tear, and should be considered in the differential diagnosis of shoulder pain and shoulder girdle muscle weakness.

Proprioception in the posterior cruciate ligament deficient knee.

This study was undertaken to evaluate knee proprioception in patients with isolated unilateral posterior cruciate ligament (PCL) injuries. Eighteen subjects with isolated PCL tears were studied 1-234 months after injury. The threshold to detect passive motion (TTDPM) was used to evaluate kinesthesia and the ability to passively reproduce passive positioning (RPP) to test joint position sense. Two starting positions were tested in all knees: 45 degrees (middle range) and 110 degrees (end range) to evaluate knee proprioception when the PCL is under different amounts of tension. TTDPM and RPP were tested as the knee moved into flexion and extension from both starting positions. A statistically significant reduction in TTDPM was identified in PCL-injured knees tested from the 45 degrees starting position, moving into flexion and extension. RPP was statistically better in the PCL-deficient knee as tested from 110 degrees moving into flexion and extension. No difference was identified in the TTDPM starting at 110 degrees or in RPP with the presented angle at 45 degrees moving into flexion or extension. These subtle but statistically significant findings suggest that proprioceptive mechanoreceptors may play a clinical role in PCL-intact and PCL-deficient patients. Further, it appears that kinesthesia and joint position sense may function through different mechanisms.

Lateral ankle sprains: a comprehensive review: part 1: etiology, pathoanatomy, histopathogenesis, and diagnosis.

Ankle sprains are among the most common injuries sustained by athletes and seen by sports medicine physicians. Despite their prevalence in society, ankle sprains still remain a difficult diagnostic and therapeutic challenge in the athlete, as well as in society in general. The purpose of this section of our two-part study is to review scope of the problem, the anatomy and biomechanics of the lateral ankle ligaments, review the pathoanatomical correlates of lateral ankle sprains, the histopathogenesis of ligament healing, and define the mechanisms of injury to understand the basis of our diagnostic approach to the patient with this common acute and chronic injury. We extensively review the diagnostic evaluation including historical information and physical examination, as well as options for supplementary radiographic examination. We further discuss the differential diagnosis of the patient with recurrent instability symptoms. This will also serve as the foundation for part two of our study, which is to understand the rationale for our treatment approach for this common problem.

Lateral ankle sprains: a comprehensive review part 2: treatment and rehabilitation with an emphasis on the athlete.

This is the second part of a two-part comprehensive review of lateral ankle sprains. In the first part of our review, we discussed the etiology, natural history, pathoanatomy, mechanism of injury, histopathogenesis of healing, and diagnostic approach to acute and chronic lateral ligamentous ankle injuries. Conservative intervention and treatment of grade I-III and chronic, recurrent sprains of the lateral ankle ligaments and appropriate rehabilitation guidelines are the topics of this article. We review the use and benefit of different modalities and external supports and outline our five-phase intervention program of rehabilitation based on the histopathogenesis of ligament healing. We discuss the expected timing of recovery of the acute injury as well as the management of chronic, recurrent ankle sprains. Treatment of acute ankle sprains depends on the severity of the injury. Conservative therapy has been found to be uniformly effective in treating grade I and II ankle sprains. Some controversy exists regarding the appropriate treatment of grade III injuries, particularly in high-level athletes. Our belief is that the majority of these patients may also be treated well with conservative management. Other options for the management of grade III sprains will be briefly discussed at the end of this article.

Peroneal tendon subluxation in athletes: new exam technique, case reports, and review.

Traumatic peroneal tendon subluxation is an uncommon cause of ankle pain. As a result, the diagnosis is often delayed. A new technique of examining the patient in the prone position, allowing for easier visualization of the subluxation or dislocation, is described. Three illustrative cases, including a rare case of midsubstance rupture of the peroneal retinaculum are presented along with a review the literature. An acute repair in athletes and in those patients who do not want to risk the chance of a 40-50% failure rate after 4-6 wk of casting is currently recommended. Surgical repair can be facilitated using Mitek suture anchors for acute, symptomatic chronic, and subacute injuries. Deepening of the groove is performed only in those patients that have no sulcus or a convexity of the groove.

The effects of joint position and direction of joint motion on proprioceptive sensibility in anterior cruciate ligament-deficient athletes.

We studied a group of anterior cruciate ligament-deficient athletes to identify whether joint position and direction of joint motion have a significant effect on proprioception. Twenty-nine anterior cruciate ligament-deficient athletes were tested for their threshold to detect passive motion at both 15 degrees and 45 degrees moving into the directions of both flexion and extension. The single-legged hop test was used to identify function in the deficient limb. Results demonstrated statistically significant deficits in threshold to detect passive motion for the deficient limb at 15 degrees moving into extension. For the deficient limb, threshold to detect passive motion was significantly more sensitive moving into extension than flexion at a starting angle of 15 degrees; at a starting angle of 15 degrees moving into extension threshold was significantly more sensitive than at a starting angle of 45 degrees moving into extension. We conclude that in deficient limbs proprioception is significantly more sensitive in the end ranges of knee extension (15 degrees) and is significantly more sensitive moving into the direction of extension. To effectively restore reflex stabilization of the lower limb we recommend a rehabilitation program emphasizing performance-based, weightbearing, closed kinetic chain exercise for the muscle groups that act on the knee joint.

Technical considerations of revision anterior cruciate ligament surgery.

Revision anterior cruciate ligament surgery will become more common as the number of primary anterior cruciate ligament reconstructions increases. Also contributing to this increase are those patients who had anterior cruciate ligament reconstruction using synthetic ligaments and other nonanatomic techniques that are no longer used. Preoperative planning is imperative to a successful outcome. This begins with determining the primary, and often times secondary, mechanism of failure for each patient. The determination of the etiology of failure is the first step in a carefully constructed preoperative plan, including the type of revision, skin incision, graft removal, hardware removal, tunnel placement, graft selection, graft fixation, and rehabilitation. The precise preoperative plan should have enough flexibility to accommodate unanticipated findings in the operating room. Rehabilitation protocols must be designed specifically for the revision surgery patient and be flexible enough to accommodate changes based on surgical findings and techniques. Finally, the importance of counseling the patient preoperatively regarding the potential results which, in general, are somewhat less satisfactory than with most primary reconstructions, must be emphasized. However, with proper planning, attention to detail, and adherence to basic principles of anterior cruciate ligament reconstruction, revision anterior cruciate ligament surgery can provide a satisfying solution to difficult knee instability cases.

Elbow problems in the athlete.

Athletes expose their elbows to significantly high forces, in addition to multiple repetitive motions. Athletic injuries about the elbow include ligamentous, tendon, articular, and nerve injuries. The proper diagnosis requires a thorough knowledge of the anatomy, pathomechanics, and physical findings associated with these injuries. Treatment entails a methodical progression from nonoperative to operative intervention.

Uncommon causes of knee pain in the athlete.

There are many causes of knee pain in the athlete. Clearly, common things, such as meniscal tears, ligament sprains, contusions, and patellofemoral dysfunction, are common. The infrequency of other entities, however, should not make the physician complacent. A thorough history and physical examination will, in most cases, elicit inconsistencies in the occasional athlete presenting with one of these uncommon causes of knee pain (Table 1). Diagnosing these uncommon causes, when they do present to the health care provider, allows for early and correct treatment with a more rapid return to sports.

Automotive airbag-related upper extremity injuries: a report of three cases.

Automotive airbag technology has reduced the number of injuries and fatalities resulting from motor vehicle crashes. With the increasingly frequent application of this safety feature in automobiles, recent reports of airbag-associated injuries have emerged, including ocular and non-lethal cardiac trauma. We report three cases of airbag-related upper extremity injuries seen at a level-I trauma center over a 6-month period. A heightened awareness of this type of injury in patients injured in motor vehicle crashes with airbag deployment is recommended. The awareness, identification, and management of these high energy injuries will take on added meaning as the airbag technology becomes universally applied.

Local anesthesia for knee arthroscopy. Efficacy and cost benefits.

We performed a retrospective review of a series of knee arthroscopic procedures that were completed using local, general, or regional anesthesia to evaluate the efficacy of these anesthetic techniques. Operative time, complications or failures, procedures successfully performed, recovery room time and postoperative stay, and patient satisfaction were recorded. Local anesthesia with intravenous sedation compared favorably with the other techniques: operative time was not increased, a large variety of operative procedures were successfully completed, recovery time was significantly shortened, and patient satisfaction remained high. This technique offers several advantages over other types of anesthesia for knee arthroscopy, including improved cost effectiveness.

Elbow injuries in athletes. A review.

Elbow injuries are becoming more common as increasing numbers of people participate in throwing and racquet sports. The understanding and treatment of elbow injuries is becoming more sophisticated in conjunction with better noninvasive and invasive diagnostic techniques. The majority of injuries to the elbow in the athlete are chronic, overuse injuries. These injuries are the result of repetitive intrinsic or extrinsic overload, or both, resulting in microrupture of soft tissue such as ligament or tendon. In children, apophyses, being the weakest link in the immature musculoskeletal system, are susceptible to stress injuries. Elbow injuries are most commonly caused by valgus stress, from throwing or axial compression, resulting in increased force absorbed by the medial elbow. With repetitive valgus stress, patients may develop chondromalacia, loose bodies in the posterior or lateral compartments, injury to the ulnar collateral ligament, myotendinous injury to the flexor-pronator muscle group, osteochondritis dissecans, or ulnar neuritis. The purpose of this paper is to (1) define the significance of elbow injuries in athletics, (2) review the anatomy and biomechanics of the elbow, and (3) discuss the prevention and treatment of elbow injuries.

Graft selection in knee surgery. Current concepts.

Recent advances in the understanding of knee mechanics and pathomechanics, in addition to newer techniques and instrumentation, have resulted in broadened indications for knee ligament surgery. Further, revision knee ligament or tendon surgery and delayed primary reconstruction are becoming more common as well. With the poor results of primary suture repair of the cruciate ligaments and the lateral collateral ligament, other graft sources often must be used. As a result, one must be familiar with the advantages and disadvantages of the different graft options available to the knee surgeon. This article discusses the current concepts regarding the advantages and disadvantages of the different graft options available to the knee surgeon.

Dorsal defect of the patella.

Dorsal defect of the patella is a benign subchondral lesion of unknown etiology, located in the superolateral region of the patella. The lesion presents with a characteristic radiographic appearance consisting of a rounded focus of radiolucency surrounded by a sclerotic margin. Although often an incidental finding on knee radiographs, it occasionally may be symptomatic. It occurs in males and females with equal frequency, is bilateral in up to one third of individuals, and is most frequently found in adolescents. This report describes a series of eight such lesions in five patients.

151 endoprosthetic reconstructions for patients with primary tumors involving bone.

As part of the UCLA limb salvage program, 151 patients received 151 endoprostheses for primary tumors involving bone. Follow-up of all patients was to death (56), revision (21), or a minimum two years for the 74 additional survivors (range: 24-114 months; mean: 52 months). Endoprosthetic replacements were of the distal femur (81), proximal femur (19), proximal humerus (13), proximal tibia (11), scapula (11), total femur (8), total humerus (4), intercalary prostheses (2), and one each of the distal humerus and the pelvis. There were three soft tissue sarcomas, five benign bone lesions, and 143 primary malignant tumors of bone. MSTS function was good-excellent in 78%. There were 64 local complications in 55 patients (36%). Mechanical failure occurred in 24 patients (15.9%), local recurrence occurred in ten (6.6%), minor wound healing problems in nine (5.9%), and infection in eight (5.3%). Few systemic complications were reported. Function appeared to be location dependent. All of the 29 patients with benign or low grade malignant tumors (parosteal, IA, IB) have survived. Of the 116 patients with stage IIA and IIB disease, 59% survived three years, and a Kaplan-Meier analysis projects that 56% are expected to survive at five years. Only 17 (11%) of these 151 endoprostheses have been revised; an additional four (3%) eventually came to amputation. The Kaplan-Meier analysis revealed that 91% of the prostheses survived three years and 83% survived five years. The Cox Proportional Hazards model revealed that for patients with stage IIA and IIB disease, the risk of death is four times the risk of the need for revision at five years. Although endoprosthetic reconstructions have their own unique complications, they have proven durable in this series of patients. Local problems usually can be managed without amputation, and patient satisfaction is high.